- Form DS-872 - Carrier's Annual Review of Employee's Driving Record - New York
- Form DS-874C - Supplement to: Medical Examination of Driver Report - New York
- Form DS-3 - Article 19-A Annual Affidavit of Compliance - New York
- Form DS-19 - Motor Carrier Accident and Conviction Notification Program Application - New York
- Form DS-885 - Bus Driver Add/Drop Notice - New York
- Form IRP-21 - IRP TEAR Request Form - New York
Fillable Printable Form DS-872 - Carrier's Annual Review of Employee's Driving Record - New York
Fillable Printable Form DS-872 - Carrier's Annual Review of Employee's Driving Record - New York
Form DS-872 - Carrier's Annual Review of Employee's Driving Record - New York
I have compared the information given by the driver with the attached driver’s abstract of operating record. I have ensured that all
accident and conviction details not appearing on the driver’s abstract are listed on this form. I HAVE ATTACHED THE DRIVER’S
ABSTRACT
(S),WHICH MUST BE DATED WITHIN 30 DAYS PRIOR TO THE DATE OF THIS INTERVIEW.
I interviewed this employee and certify that this driver meets the standards for safe driving, has been instructed in, and is in
compliance with, the provisions of Article 19-A, and is qualified to drive a bus.
DS-872 (6/15)
Were you involved in ANY motor vehicle accident(s) during the past 12 months? o YES o NO If YES, complete Accident
Information section below:
ACCIDENT INFORMATION (if additional space is needed, use the back of this form)
Date
of
Accident
Location
City, State, Zip Code, County
Briefly describe property damage, type of vehicle involved and
approximate dollar value of damage for each vehicle
Number of
People
Injured
Were there
any fatalities?
YES or NO
Were you convicted of ANY traffic violation(s) (other than parking) or any crime(s) during the past 12 months? o YES o NO
If YES, complete Record of Convictions section below:
RECORD OF CONVICTIONS (if additional space is needed, use the back of this form)
Date of
Violation
Date of
Conviction
Of What Charge
Were You Convicted?
Type of
Motor Vehicle Operated
o CMV
o Non-CMV
o CMV
o Non-CMV
o CMV
o Non-CMV
Court Location
City, State, Zip Code, County
DRIVER CERTIFICATION
CARRIER CERTIFICATION
-__________________________________________________ _______________
(Driver Signature)
(Date)
-_______________________________________________________________________
(Authorized Signature of Carrier Representative)
_________________________
(Date of Interview)
www.dmv.ny.gov
(Print Name of Carrier Representative) (Title)
I certify that the information above is a true and complete list of traffic violations (other than parking violations) for which I have
been convicted or forfeited bond or collateral during the past 12 months, and accidents I was involved in during the past 12
months. If no violations or accidents are listed above, I certify that I have not been convicted or forfeited bond or collateral on
account of any violation required to be listed during the past 12 months, or have been involved in any accidents during the past 12
months.
Driver’s Last Name
Street Address 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)
DRIVER INFORMATION
Carrier/DBA Name Legal Name (if different)
Street Address City State Zip Code
Federal ID Number 19-A Business ID Number
CARRIER INFORMATION
CARRIER’S ANNUAL REVIEW OF EMPLOYEE’s DRIVING RECORD
UNDER ARTICLE 19-A
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