Ds 876A Form – Fill Out and Use This PDF

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REQUIREMENTS: CompleteandattachthisformtoformDS-876(ApplicationforArticle19-ACertifiedExaminer). PLEASEPRINTCLEARLY.

NOTE: ACertifiedExaminermusthaveatleasttwoyearsofexperienceindrivertrainingandinevaluatingthedrivingabilityofothers.

●ThisformisusedtoprovideinformationaboutthetraineeslistedintheExperiencesectionofformDS-876(ApplicationforArticle19-ACertifiedExaminer), andisanaffidavitbytheemployerthattheapplicanthasmettheexperiencerequirementwhileemployedbysuchemployer.

●AseparateaffidavitmustbeprovidedbyeachemployeridentifiedintheExperiencesectionofformDS-876.ThetraineeslistedintheTrainees sectionbelowmusthaveworkedfortheemployersigningtheaffidavitonpage2ofthisform.

The APPLICANT completes page 1 and signs pages 1 and 2 of this form. Page 2 must be notarized. The trainees listed in the Trainees section below must includeonlythetraineesnotedintheExperiencesectionofformDS-876.

The EMPLOYER verifies that the applicant trained and evaluated the trainees noted in the Trainees section of this form by completing the affidavit on page2.The EMPLOYER mustcomplete,signandhavethissectionnotarized.

APPLICANT INFORMATION

Driver’s Last Name

First

M.I.

Date of Birth (Month/Day/Year)

Street Address

City

State

Zip Code

Client/License ID Number

State

Class of Driver’s License

Endorsements

Restrictions

Expiration Date

(from Driver License)

TRAINEES

Trainee Name

Telephone Number

	(	)
Trainee Address
Trainee Name	Telephone Number
	(	)
Trainee Address
Trainee Name	Telephone Number
	(	)
Trainee Address
Trainee Name	Telephone Number
	(	)
Trainee Address
Trainee Name	Telephone Number
	(	)
Trainee Address

I have trained and evaluated the driving ability of the individual(s) named above as part of my job duties while employed by an Article 19-A Motor Carrier. The training and evaluation that I conducted consisted of actual on-the-road situations in which I observed each driver’s defensive driving skills and ability to safely and properly operate the vehicle. To the best of my knowledge, the above information is true and correct. I understand that any false statement I makeonthisformisamisdemeanorunderSection392oftheVehicleandTrafficLaw.

➧

(Signature of Applicant)

(Date)

PAGE 1 OF 2

EMPLOYER INFORMATION

AFFIDAVIT - (To be completed by Employer)

I,______________________________________________,astheemployerof ____________________________________,

(Employer/Supervisor)(Name of Applicant)

certifythathe/sheis/wasemployedby __________________________________________________________

(Employer Name)

asa________________________________________________from_____________________to_____________________

(Type of Job)(MM/DD/YYYY) (MM/DD/YYYY)

andwasafull-timeClass_________ operator,andthathe/sheworkedasadrivertrainerandevaluatorofthedrivingability

(Class of

license)

ofotherClass_________ drivers,includingthosetraineeslistedonpageoneofthisformfor_________years.

(Class of

license)

Tothebestofmyknowledge,theaboveinformationistrueandcorrect.IunderstandthatanyfalsestatementImakeon thisaffidavitispunishableasamisdemeanorunderSection392oftheVehicleandTrafficLaw.

➧___________________________________________________________________ ___________________________

(Signature of Employer/Supervisor)

(Date)

➧___________________________________________________________________ ___________________________

(Signature of Applicant)

(Date)

Sworntobeforemeon_______________________________________,______________.

(Year)

__________________________________________________________________________

(Notary Public Signature)

NotaryCommissionNumber________________________________________State ________________

CommissionExpireson____________________________________________County_______________

DS-876A (11/08)

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