Fillable Printable Form DS-876 - Application for Article 19-A Certified Examiner - New York

Form DS-876 - Application for Article 19-A Certified Examiner - New York

BUS DRIVER UNIT

APPLICATION FOR ARTICLE 19-A CERTIFIED EXAMINER

www.dmv.ny.gov

PAGE 1 OF 2

Complete page 1 and page 2 of this form and sign the Affirmation section. Please print clearly.

In order to be certified, you must have a valid commercial driver license with appropriate endorsements. You must be properly licensed

in the class in which you will be testing drivers.

If your commercial driver license was issued by a state other than New York, attach a recent certified driver license abstract from the

state that issued your license.

You must have an acceptable driving record (no more than 6 points accumulated on your record within the preceding 18-month period).

Mail this completed, signed form and required documentation to the following address:

Bus Driver Unit

NYS Department of Motor Vehicles

6 Empire State Plaza Room 136B

Albany, NY 12228

If your application meets initial qualification standards, you will be notified by mail to contact a Motor Vehicles Testing and Investigation

Unit to schedule a Certified Examiner qualifying interview that will include a written test, a vision test, and a road test.

Do not contact the

Motor Vehicles Office until you receive that notice.

INSTRUCTIONS/INFORMATION

APPLICANT INFORMATION

E-mail Address

Daytime Telephone No.

( )

Certification Class Requested - Check Class of vehicle in which

you will be testing.

Federal Employer ID Number (FEIN)

Name of Current 19-A Carrier Employer

Freelance - Occasionally DMV will get requests for the names of Certified Examiners who

are available to do independent examiner work.

Do you want to be included on such a list?

o Yes o No

o Class B o Class C

DS-876 (6/15)

Driver’s Last Name

Street Address

City

State Zip Code

Endorsements

Restrictions Expiration Date

ID Number from Driver License

State

First Name Middle Initial

Date of Birth (mm/dd/yyyy)

/ /

oMale oFemale

License Class

Article 19-A Business ID Number

County

EXPERIENCE

I have a minimum of 2 years experience in driver training and the evaluation of the driving ability of others.

(Provide information about

your employer(s) below. Attach a separate sheet if you need more space to document your experience.)

I have a minimum of 18 months experience in the last 3 years while employed by a 19-A carrier in the operation of the type of vehicle

in which I will be testing.

(Provide information about your employer(s) below. Attach a separate sheet if you need more space to document

your experience.)

AND

I hereby make application to test drivers in accordance with the mandates of Article 19-A of the New York State Vehicle and Traffic Law. To the

best of my knowledge, the information provided is true and correct. I understand that any false statement I make on this application is

punishable as a misdemeanor under Section 392 of the New York State Vehicle and Traffic Law.

Applicant’s Signature: ________________________________________________________ _______ Date: ____________________

I endorse this applicant to be a Certified Examiner for my company.

Current 19-A Employer Name (please print): __________________________________________________________________________

Current 19-A Employer’s Signature: ____________________________________________________ Date: _____________________

EDUCATION

I have successfully completed a college-level course with a minimum of 4 credit hours in driver education instruction.

(Attach a copy of your transcript.)

I have successfully completed a DMV-approved course in driver training and traffic safety for 19-A Certified Examiners.

(Attach a copy of your course certificate.)

In addition to the above experience, you MUST have completed one of the following courses. Check the box that applies to you.

EXCEPTION

You may be able to provide special affidavits if you do not have a minimum of 18 months experience in the last 3 years while employed by a

19-A carrier in the operation of the type of vehicle in which you will be testing. Attach documentation outlining your experience and training

and any other special circumstance which might qualify you to become a certified examiner. The Bus Driver Unit will review your

information and determine whether it is acceptable.

Employer Name and Address

Dates Employed

Class of

License Held

From:

PAGE 2 OF 2

DS-876 (6/15)

Employer Name and Address

Dates Employed

Class of

License Held

From: To:

To:

AFFIRMATION

CARRIER ENDORSEMENT

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