Form DS-872 "Carrier's Annual Review of Employee's Driving Record Under Article 19-a" - New York

What Is Form DS-872?

This is a legal form that was released by the New York State Department of Motor Vehicles - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2016;
  • The latest edition provided by the New York State Department of Motor Vehicles;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DS-872 by clicking the link below or browse more documents and templates provided by the New York State Department of Motor Vehicles.

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Download Form DS-872 "Carrier's Annual Review of Employee's Driving Record Under Article 19-a" - New York

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CARRIER’S ANNUAL REVIEW OF EMPLOYEE’s
DRIVING RECORD UNDER ARTICLE 19-A
DRIVER INFORMATION
Driver’s Last Name
First
.
Date of Birth (Month/Day/Year)
M.I
Class of Driver’s License Endorsements
Restrictions
Expiration Date
License ID Number
State
(from Driver License)
CARRIER INFORMATION
Carrier/DBA Name
Federal ID Number
19-A Business ID Number
Legal Name (if different)
Were you involved in ANY motor vehicle accident(s) during the past 12 months that do not appear on your abstract?
o
o
YES
NO
If YES, complete Accident Information section below:
ACCIDENT INFORMATION (if additional space is needed, use the back of this form)
Date
Number of
Were there
of
Location
Briefly describe property damage, type of vehicle involved and
People
any fatalities?
Accident
City, State, Zip Code, County
approximate dollar value of damage for each vehicle
Injured
YES or NO
Were you convicted of ANY traffic violation(s) (other than parking) or any crime(s) during the past 12 months that do not appear
o
o
on your abstract?
YES
NO
If YES, complete Record of Convictions section below:
RECORD OF CONVICTIONS (if additional space is needed, use the back of this form)
Date of
Date of
Of What Charge
Type of
Court Location
Violation
Conviction
Were You Convicted?
Motor Vehicle Operated
City, State, Zip Code, County
o
CMV
o
Non-CMV
o
CMV
o
Non-CMV
o
CMV
o
Non-CMV
DRIVER CERTIFICATION
I certify that the information above is a true and complete list of traffic violations (other than parking violations) for which I have
been convicted or forfeited bond or collateral during the past 12 months, and accidents I was involved in during the past 12
months. If no violations or accidents are listed above, I certify that I have not been convicted or forfeited bond or collateral on
account of any violation required to be listed during the past 12 months, or have been involved in any accidents during the past 12
months that is not already listed on my license abstract.
X
(Driver Signature)
(Date)
CARRIER CERTIFICATION
I have compared the information given by the driver with the attached driver’s abstract of operating record. I have ensured that
all accident and conviction details not appearing on the driver’s abstract are listed on this form. I
HAVE ATTACHED THE DRIVER
S
(
),
30
.
ABSTRACT
S
WHICH MUST BE DATED WITHIN
DAYS PRIOR TO THE DATE OF THIS INTERVIEW
I interviewed this employee and certify that this driver meets the standards for safe driving, has been instructed in, and is in
compliance with, the provisions of Article 19-A, and is qualified to drive a bus.
(Print Name of Carrier Representative)
Title)
(
X
(Authorized Signature of Carrier Representative)
(Date of Interview)
DS-872 (5/16)
dmv.ny.gov
reset/clear
reset/clear
CARRIER’S ANNUAL REVIEW OF EMPLOYEE’s
DRIVING RECORD UNDER ARTICLE 19-A
DRIVER INFORMATION
Driver’s Last Name
First
.
Date of Birth (Month/Day/Year)
M.I
Class of Driver’s License Endorsements
Restrictions
Expiration Date
License ID Number
State
(from Driver License)
CARRIER INFORMATION
Carrier/DBA Name
Federal ID Number
19-A Business ID Number
Legal Name (if different)
Were you involved in ANY motor vehicle accident(s) during the past 12 months that do not appear on your abstract?
o
o
YES
NO
If YES, complete Accident Information section below:
ACCIDENT INFORMATION (if additional space is needed, use the back of this form)
Date
Number of
Were there
of
Location
Briefly describe property damage, type of vehicle involved and
People
any fatalities?
Accident
City, State, Zip Code, County
approximate dollar value of damage for each vehicle
Injured
YES or NO
Were you convicted of ANY traffic violation(s) (other than parking) or any crime(s) during the past 12 months that do not appear
o
o
on your abstract?
YES
NO
If YES, complete Record of Convictions section below:
RECORD OF CONVICTIONS (if additional space is needed, use the back of this form)
Date of
Date of
Of What Charge
Type of
Court Location
Violation
Conviction
Were You Convicted?
Motor Vehicle Operated
City, State, Zip Code, County
o
CMV
o
Non-CMV
o
CMV
o
Non-CMV
o
CMV
o
Non-CMV
DRIVER CERTIFICATION
I certify that the information above is a true and complete list of traffic violations (other than parking violations) for which I have
been convicted or forfeited bond or collateral during the past 12 months, and accidents I was involved in during the past 12
months. If no violations or accidents are listed above, I certify that I have not been convicted or forfeited bond or collateral on
account of any violation required to be listed during the past 12 months, or have been involved in any accidents during the past 12
months that is not already listed on my license abstract.
X
(Driver Signature)
(Date)
CARRIER CERTIFICATION
I have compared the information given by the driver with the attached driver’s abstract of operating record. I have ensured that
all accident and conviction details not appearing on the driver’s abstract are listed on this form. I
HAVE ATTACHED THE DRIVER
S
(
),
30
.
ABSTRACT
S
WHICH MUST BE DATED WITHIN
DAYS PRIOR TO THE DATE OF THIS INTERVIEW
I interviewed this employee and certify that this driver meets the standards for safe driving, has been instructed in, and is in
compliance with, the provisions of Article 19-A, and is qualified to drive a bus.
(Print Name of Carrier Representative)
Title)
(
X
(Authorized Signature of Carrier Representative)
(Date of Interview)
DS-872 (5/16)
dmv.ny.gov
reset/clear
reset/clear