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Fillable Printable Form DS-879 - Article 19-A Carrier Application - New York

Fillable Printable Form DS-879 - Article 19-A Carrier Application - New York

Form DS-879 - Article 19-A Carrier Application - New York

Form DS-879 - Article 19-A Carrier Application - New York

ARTICLE 19-A CARRIER APPLICATION
New York State Department of Motor Vehicles
Bus Driver Unit
6 Empire State Plaza, Room 136B
Albany NY 12228
The carrier must complete this form and mail it to:
DS-879 (6/15)
www.dmv.ny.gov
NYS DOT Number (required if applicable)
Federal Employer ID Number
Motor Carrier’s Legal Name
Motor Carrier’s Assumed/DBA Name (If applicable)
Mailing Address
City
Physical Address (if different from mailing address)
E-mail Address
CERTIFICATION: By making this Application, the undersigned certifies under penalty of perjury that s/he is a duly authorized
representative of the motor carrier named herein; that this application is made on behalf of, and with the authority to bind, such
entity; and that all information provided herein is true and complete. By making this Application, the motor carrier agrees to be
compliant with the provisions of Article 19-A and the Terms of Use of the Electronic Web Application for the New York State
Department of Motor Vehicles 19-A System; and certifies that all individuals responsible for the management, maintenance and
operation for the motor carrier have been advised of their obligations thereunder.
MOTOR CARRIER TYPE (check one)
Non-School Motor Carrier
School Motor Carrier
School and Non-School Motor Carrier
LIAISON/CONTACT INFORMATION
State Zip Code County
US DOT Number (required if applicable)
Name of Liaison for 19-A Online System Liaison’s E-mail Address
Name of Motor Carrier’s Contact Representative for Article 19-A Matters
City
State Zip Code County
Any questions regarding this form should be directed to the
Bus Driver Unit at (518) 473-9455.
ç
Telephone Number (include Area Code)
( ) ext.
Fax Number (include Area Code)
( )
Title E-mail AddressTelephone Number (include Area Code)
( ) ext.
AUTHORIZED REPRESENTATIVE - MUST be one of the following titles:
Business Owner, General Partner, duly authorized Corporate Officer, LLC Managing Member, School Superintendent
OFFICE USE ONLY
19-A Business ID Number
Name E-mail Address
Title (Owner/President/Superintendent, etc.)
Signature
Date (mm/dd/yyyy)
/ /
Telephone Number (include Area Code)
( ) ext.
CHECK ALL THAT APPLY
Governmental (Federal, State, County, Local, Public Authority)
Non-Governmental
Contracted School
Camp
Day Care
Van
Transit
Limousine
Ambulette/Paratransit
Religious Other ______________________
reset/clear
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