Fillable Printable Form DS-870 - Article 19-A Bus Driver Application - New York

Form DS-870 - Article 19-A Bus Driver Application - New York

ARTICLE 19-A BUS DRIVER APPLICATION

(Complete all parts of this form. Please print or type.

Send original to Bus Driver Unit, keep a copy in your driver 19-A file.)

DRIVER AFFIRMATION: To the best of my knowledge, the information I have given on this application is true.

Signature of Driver

- ________________________________________________________ Date ________________________________

EMPLOYER CERTIFICATION: This application has been reviewed together with the driver abstract and medical examination (form DS-874 or

USDOT form 649-F or equivalent) and the applicant is hereby classified as a “conditional driver” as defined in Section 6.2(r) and in accordance

with the requirements of Sections 6.3 and 6.4 of the regulations of the Commissioner of Motor Vehicles. Final approval of employment is subject

to the applicant meeting the requirements of Article 19-A of the New York State Vehicle and Traffic Law. All questions pertaining to this form and/or

the Article 19-A Program should be directed to: New York State Department of Motor Vehicles, Bus Driver Unit, 6 Empire State Plaza, Rm 220C,

Albany NY 12228, (518) 473-9455.

DS-870 (6/15)

ADDITIONAL DRIVER INFORMATION

Provide your employment, accident, and conviction history and answer the questions below. If necessary, attach additional pages.

1. Have you qualified as a school bus driver under ARTICLE 19-A?

oYes o No If “yes”, give month and year of qualification __________

2. Are you a certified ARTICLE 19-A examiner?

o Yes o No

If “yes”, give certificate number _________________________ and expiration date ___________________.

EMPLOYMENT (Start with your most recent employment, and include work

history for the past 3 years):

ACCIDENTS (Start with your most recent accident, and include accidents within the past 3 years):

Employer Name and Address

What were the date(s)

of your employment?

(From - To)

Date of Accident

Location

(City, State, Zip Code, County)

Was there personal injury or property damage?

If “YES”, indicate the dollar amount of damage to each

vehicle, and the number of people injured.

What type of vehicle were you driving?

Your job title

CONVICTIONS (Start with your most recent conviction, and include all criminal convictions):

Date of Violation

Location

(City, State, Zip Code, County) Date of Conviction Of what charge were you convicted?

If a vehicle was involved, what type

of vehicle were you driving?

Signature of Employer/Agent - ________________________________________________ Date ________________________________

www.dmv.ny.gov

DRIVER INFORMATION

Driver’s Last Name

Street Address

Carrier/DBA Name Legal Name (if different)

Street Address City State Zip Code

19-A Business ID NumberFederal ID Number

City State Zip Code

Class of Driver’s License Endorsements Restrictions Expiration Date

Client/License ID Number

(from Driver License)

State

First M.I. Date of Birth (Month/Day/Year)

County Telephone Number

Social Security Number

oMale o Female

CARRIER INFORMATION

Name of Article 19-A Contact Person Title Is this employer/carrier a school bus carrier?

oYe s o No

County Telephone Number

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