Fillable Printable Form DS-875Y - Article 19-A Oral/Written Examination Results - New York

Form DS-875Y - Article 19-A Oral/Written Examination Results - New York

ARTICLE 19-A ORAL/WRITTEN EXAMINATION RESULTS

I certify that I have tested the above driver in compliance with Section 6.12 and/or Section 6.15 of Part 6 of the

Commissioner’s Regulations. The employer has been notified of the results.

DS-875Y (6/15)

www.dmv.ny.gov

Certified Examiner’s

Signature

Date of Examination

TYPE OF EXAMINATION

o Oral o Written o Re-examination

DRIVER EXAMINATION RESULTS

EXAMINER’S CERTIFICATION

o Passed o Failed - Driver Disqualified

INSTRUCTIONS TO CERTIFIED EXAMINER

After administering the exam, and using the answer key provided (Form DS-875Z, “Article 19-A Written Examination

Answer Sheet”), complete this form and attach it to the driver’s completed examination.

DRIVER INFORMATION

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)

Driver Signature

State

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

CARRIER INFORMATION

Carrier/DBA Name Legal Name (if different)

Street Address City State Zip Code

Federal ID Number 19-A Business ID Number

Certified Examiner’s Name

Certificate Number Certification Class Expiration DateEndorsements

Restrictions

Client/License ID Number

(from Driver License)

reset/clear