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Fillable Printable Form DS-873 - Driver Annual Defensive Driving Performance Report - New York

Fillable Printable Form DS-873 - Driver Annual Defensive Driving Performance Report - New York

Form DS-873 - Driver Annual Defensive Driving Performance Report - New York

Form DS-873 - Driver Annual Defensive Driving Performance Report - New York

I acknowledge discussion of my defensive driving performance with the examiner who observed and rated my performance.
REPORT ON ANNUAL DEFENSIVE DRIVING
PERFORMANCE FOR DRIVER UNDER ARTICLE 19-A
www.dmv.ny.gov
DS-873 (6/15)
SECTION 1 - DRIVER INFORMATION
Driver’s Last Name
Street Address
Street Address City State Zip Code
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)
SECTION 2 - CARRIER INFORMATION
SECTION 4 - OBSERVATION (may be conducted inside or outside the vehicle) Observation Conducted: o Inside o Outside
SECTION 5 - DRIVER ACKNOWLEDGEMENT
__________________________________________________ _______________
(Driver Signature) (Date)
Type of Vehicle Adult Seating Capacity
SECTION 3 - VEHICLE INFORMATION
GVWR Vehicle Plate Number State
Satisfactory Unsatisfactory
1. Observation ........................................ o o
2. Traffic Lane Use
(include center line violation) ............ o o
3. Speed.................................................. o o
4. Properly Signals Intention .................. o o
5. Turning ................................................ o o
6. Vehicle Control.................................... o o
Satisfactory Unsatisfactory
7. Obeys Traffic Signs, Signals
and Road Hazard Signs...................... o o
8. Observes Proper Following Distance.. o o
9. Procedures for Receiving and
Discharging Passengers .................... o o
10. Traffic Interaction ................................ o o
INSTRUCTIONS TO CERTIFIED EXAMINER:
l Regular observation of a driver’s defensive driving performance must be conducted while the driver is operating the vehicle with passengers.
l This observation shall NOT be conducted on the same day as the biennial behind-the-wheel road test.
l Discuss performance with driver, complete rating, driver acknowledgement, and examiner certification.
Comments: (required if Unsatisfactory checked above)
-
Certified Examiner’s Name
Certificate Number Certification Class Expiration DateEndorsements
Restrictions
Certified Examiners Signature
-
I certify that the above report is, to the best of my knowledge, true and correct,
that I personally observed the above drivers defensive driving performance, and
that I currently hold a valid examiner certification as required in accordance with
Article 19-A of the New York State Vehicle and Traffic Law.
Client/License ID Number
(from Driver License)
SECTION 6 - EXAMINER’S CERTIFICATION
Date of Observation
Carrier/DBA Name Legal Name (if different) Federal ID Number 19-A Business ID Number
reset/clear
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