Form CDL-VRU Issued 2/00 State Form # 49793 Indiana Department of Revenue Application for Authorization CDL VRU System Name of Company US DOT Number Address City, State, and Zip Daytime Telephone Number Contact Person The undersigned company owner or responsible officer submits this application for use of the Voice Response Unit (VRU) system. The purpose of using the VRU is to check the status of a driver’s Department of Transportation physical examination form. I also understand that I am making this application with the agreement that an authorization number will be assigned for the sole use of this company to use to check on this company’s driver’s DOT physicals. Under penalties of perjury, I declare that I have examined this document and to the best of my knowledge and belief, it is true, correct, and complete. Signature of Owner or Responsible Officer Date Typed or Printed Name Title Return this application to: Indiana Department of Revenue CDL Section - Attn: Carol Grubbs 5252 Decatur Blvd. Suite R Indianapolis, IN 46241-9524 American LegalNet, Inc. www.FormsWorkflow.com