- 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 IRP-21 - IRP TEAR Request Form - New York
- Form DS-885 - Bus Driver Add/Drop Notice - New York
- Form DS-19 - Motor Carrier Accident and Conviction Notification Program Application - New York
- Form DS-872 - Carrier's Annual Review of Employee's Driving Record - New York
Fillable Printable Form DS-877 - Article 19-A Certified Examiner Application Form - New York
Fillable Printable Form DS-877 - Article 19-A Certified Examiner Application Form - New York
Form DS-877 - Article 19-A Certified Examiner Application Form - New York
BUS DRIVER UNIT
ARTICLE 19-A CERTIFIED EXAMINER
APPLICATION FOR RENEWAL OR AMENDMENT
www.dmv.ny.gov
PAGE 1 OF 3
Check the box(es) that apply, and complete only the corresponding section(s) on pages 1-3. The examiner must sign the Affirmation section
on page 3.
o RENEW CERTIFICATE - You must renew your Commercial Driver License (CDL) before you can renew your certification.
Attach an original, official abstract of your driving record if you hold an out-of-state driver license. The abstract must show that you have
renewed your CDL.
o REQUEST A DUPLICATE CERTIFICATE - Provide a reason for your request.
o UPGRADE CERTIFICATION CLASS - Apply for an upgrade in Certification Class from a C to a B.
o ARTICLE 19-A REFRESHER SEMINAR - Report completion of an Article 19-A refresher seminar that must be completed at least
once every three years. Attach a copy of your completion certificate.
o AMEND PERSONAL INFORMATION - Amend examiner personal information (such as telephone number or e-mail address).
o EMPLOYER - Add or drop an employer.
o FREELANCE WORK - Add or remove your name from DMV’s list of examiners who will do independent examiner work.
NOTE: You are required by law to notify DMV within 10 days of any PERMANENT address change. You may print form MV-232 (Change of
Address) by going to the DMV web site at www.dmv.ny.gov, or you can obtain one by going to any Motor Vehicles office.
DS-877 (6/15)
CERTIFIED EXAMINER INFORMATION
RENEW CERTIFICATE
INSTRUCTIONS
o Yes, I have renewed my CDL and, within the last three years, have completed the required Article 19-A refresher seminar.
REQUEST A DUPLICATE CERTIFICATE
o I am requesting a duplicate certificate because:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Driver’s Last Name
Street Address City State Zip Code
Class of Driver License Endorsements Restrictions Expiration Date
Client/License ID Number
(from Driver License)
State
First M.I. Date of Birth (Month/Day/Year)
County Telephone Number
Social Security Number
oMale oFemale
PAGE 2 OF 3
UPGRADE CERTIFICATION CLASS
o I currently hold a Class C Certificate, and request an upgrade to a Class B. Within the last three years, I have a minimum of eighteen
months experience (while employed by an Article 19-A Motor Carrier) in the operation of the type of vehicle in which I will be testing. I
have gained this experience while employed by the following:
Note: If your request to upgrade Certification Class meets all requirements, you will be notified to contact a DMV Testing &
Investigation Unit to schedule vision and road tests.
Note: This form cannot be used to change your name. To change your name, you must complete form MV-44 (Application for Driver
License or Non-Driver ID Card) and provide appropriate proof to DMV.
Employer Name and Address
Dates Employed
Class of Driver
License Held
From: To:
1.
2.
3.
ARTICLE 19-A REFRESHER SEMINAR
A Certified Examiner is required to attend a DMV-approved Article 19-A refresher seminar at least once every three years. You must attach a
copy of your completion certificate to this form.
o I have successfully completed such course at the following place and time:
Provider Name and Address
Date of Seminar
AMEND PERSONAL INFORMATION
EMPLOYER
o The following personal information has changed:
o I have added or dropped the following employer:
Daytime Telephone No.
( )
E-mail Address
Employer Name and Address
Dates Employed
Add Drop
From: To:
1.
2.
3.
oo
oo
oo
To be completed by new employer:
I endorse this applicant to be a Certified Examiner for my company.
Federal Employer ID Number (FEIN)________________________________ 19-A Business ID Number ____________________________
Employer’s Name (please print): ______________________________________________
Employer’s Signature: _____________________________________________________ Date: __________________________________
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DS-877 (6/15)
DS-877 (6/15)
PAGE 3 OF 3
FREELANCE WORK
o Yes, I want to be added to DMV’s list of Certified Examiners who are available to do independent examiner work.
o No, I no longer want to appear on DMV’s list of Certified Examiners who are available to do independent examiner work.
AFFIRMATION
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 above information 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 Vehicle and Traffic Law.
Signature of Certified Examiner: ____________________________________________________ Date: ________________
ç
NYS Department of Motor Vehicles
Bus Driver Unit
6 Empire State Plaza, Room 311
Albany NY 12228
OFFICE USE ONLY
o19-A Experience
o Refresher
o Driver License
Not Renewed
DENIED
o DL criteria for:
oExceed Points
oNot in Class/Pass
oSusp/Rev/Exp/Surr
DENIED
o Signature
o Information
o Certificate
o O/S Abstract
COMPLETE
Complete if Required
Complete and mail this form with required documents to:
reset/clear
