Ds 877 Ds877
User Manual: 877
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ARTICLE 19-A CERTIFIED EXAMINER APPLICATION FOR RENEWAL OR AMENDMENT BUS DRIVER UNIT www.dmv.ny.gov CERTIFIED EXAMINER INFORMATION First Driver’s Last Name Date of Birth (Month/Day/Year) Social Security Number M.I. o Male o Female Telephone Number Street Address City State Zip Code License ID Number (from driver license) State Class of Driver License County Endorsements Restrictions Expiration Date INSTRUCTIONS Check the box(es) that apply, and complete only the corresponding section(s) on pages 1-3. The examiner must sign the Certification 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 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. once every three years. Attach a copy of your completion certificate. 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. RENEW CERTIFICATE 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: DS-877 (11/15) PAGE 1 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: Employer Name and Address Dates Employed From: To: Class of Driver License Held 1. 2. 3. 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. 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 Location of Class Date of Seminar: AMEND PERSONAL INFORMATION o The following personal information has changed: Daytime Telephone No. ( E-mail Address ) 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 o I have added or dropped the following employer: Employer Name and Address Dates Employed From: To: Add Drop 1. o o 2. o o 3. o o 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: DS-877 (11/15) ç _____________________________________________________ Date: __________________________________ PAGE 2 OF 3 FREELANCE WORK o o Yes, I want to be added to DMV’s list of Certified Examiners who are available to do independent examiner work. No, I no longer want to appear on DMV’s list of Certified Examiners who are available to do independent examiner work. CERTIFICATION I, the Undersigned, certify that the information I have provided in this application is true and accurate, and I have read and understood Article 19-A of the New York State Vehicle and Traffic Law and Commissioner’s Regulations, Part 6.13 (15 NYCRR 6.13). I acknowledge and 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, and the Department of Motor Vehicles (DMV) has the discretion to terminate its authorization for conducting such testing upon evidence satisfactory to DMV that I have knowingly engaged in any fraudulent or deceptive acts in connection with the conduct or reporting of any commercial driver test. Signature of Certified Examiner: ç____________________________________________________ Complete and mail this form with required documents to: Date: ________________ NYS Department of Motor Vehicles Bus Driver Unit 6 Empire State Plaza, Room 136B Albany NY 12228 OFFICE USE ONLY DENIED o DL criteria for: o o o Exceed Points Not in Class/Pass Susp/Rev/Exp/Surr DENIED COMPLETE o o Signature Information Complete if Required o o o o o 19-A Experience Refresher Driver License Not Renewed Certificate O/S Abstract reset/clear DS-877 (11/15) PAGE 3 OF 3
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