- Form IRP-33 - IRB Renewal Checklist - New York
- Form DS-3.3 - Article 19-A Motor Carrier Annual Statistical Report - New York
- Form DS-875 - Article 19-A Biennial Behind the Wheel Road Test - New York
- Form DS-103 - Report of Passing Stopped School Bus - New York
- Form DS-879 - Article 19-A Carrier Application - New York
- Form IRP-5 - Schedule B Mileage Information (2013) - New York
Fillable Printable Form DS-875Y - Article 19-A Oral/Written Examination Results - New York
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
oOral oWritten oRe-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 AddressCityStateZip Code
Class of Driver’s LicenseEndorsementsRestrictionsExpiration Date
Client/License ID Number
(from Driver License)
Driver Signature
State
FirstM.I.Date of Birth (Month/Day/Year)
CARRIER INFORMATION
Carrier/DBA NameLegal Name (if different)
Street AddressCityStateZip Code
Federal ID Number19-A Business ID Number
Certified Examiner’s Name
Certificate NumberCertification Class Expiration DateEndorsements
Restrictions
Client/License ID Number
(from Driver License)
reset/clear
