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
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 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
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 (11/15)
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
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 Location of Class
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 (11/15)
DS-877 (11/15) 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.
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: ____________________________________________________ Date: ________________
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NYS Department of Motor Vehicles
Bus Driver Unit
6 Empire State Plaza, Room 136B
Albany NY 12228
OFFICE USE ONLY
o19-A Experience
oRefresher
oDriver License
Not Renewed
DENIED
oDL criteria for:
oExceed Points
oNot in Class/Pass
oSusp/Rev/Exp/Surr
DENIED
oSignature
oInformation
oCertificate
oO/S Abstract
COMPLETE
Complete if Required
Complete and mail this form with required documents to:
reset/clear
