Form Ds 876 PDF Details

Form Ds 876 is a document that is used in order to declare an organization's financial transactions. This document can be used for both private and public organizations, and it is important to ensure that all information included in the form is accurate. By filing a Form Ds 876, an organization can keep track of its financial activity and ensure that it is compliant with any applicable laws or regulations. Filing this form also allows an organization to be transparent with its finances and provide potential investors with important information about the company. inaccuracies on this document can lead to fines or other penalties, so it is critical to get it right the first time. For more information on Form Ds 876, please contact us today.

QuestionAnswer
Form NameForm Ds 876
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesds876 ds 876a form

Form Preview Example

DS-876 (11/13)

NewYorkStateDepartmentofMotorVehicles

BUS DRIVER UNIT

APPLICATION FOR ARTICLE 19-ACERTIFIED EXAMINER

www.dmv.ny.gov

INSTRUCTIONS/INFORMATION

Completepage1andpage2ofthisformandsigntheAffirmationsection.Pleaseprintclearly.

Inordertobecertified,youmusthaveavalidcommercialdriverlicensewithappropriateendorsements.Youmustbeproperlylicensed intheclassinwhichyouwillbetestingdrivers.

IfyourcommercialdriverlicensewasissuedbyastateotherthanNewYork,attacharecentcertifieddriverlicenseabstractfromthe statethatissuedyourlicense.

Youmusthaveanacceptabledrivingrecord(nomorethan6pointsaccumulatedonyourrecordwithinthepreceding18-monthperiod).

Mailthiscompleted,signedformandrequireddocumentationtothefollowingaddress:

BusDriverUnit

NYSDepartmentofMotorVehicles

6EmpireStatePlaza Room136B

Albany,NY 12228

Ifyourapplicationmeetsinitialqualificationstandards,youwillbenotifiedbymailtocontactaMotorVehiclesTestingandInvestigation UnittoscheduleaCertifiedExaminerqualifyinginterviewthatwillincludeawrittentest,avisiontest,andaroadtest.Donotcontactthe

MotorVehiclesOfficeuntilyoureceivethatnotice.

APPLICANT INFORMATION

Driver’s Last Name

First Name

Street Address

Middle Initial Date of Birth (mm/dd/yyyy)

/ /

oMale oFemale

City

State

Zip Code

 

 

County

ID Number from Driver License

State

License Class

Endorsements

Restrictions

Expiration Date

Daytime Telephone No.

()

E-mail Address

Certification Class Requested - Check Class of vehicle in which you will be testing.

o Class B o Class C

Freelance - Occasionally DMV will get requests for the names of Certified Examiners who are available to do independent examiner work.

Do you want to be included on such a list? o Yes o No

Name of Current 19-A Carrier Employer

Federal Employer ID Number (FEIN)

Article 19-A Business ID Number

PAGE 1 OF 2

DS-876 (11/13)

EXPERIENCE

I have a minimum of 2 years experience in driver training and the evaluation of the driving ability of others. (Provide information about

youremployer(s)below.Attachaseparatesheetifyouneedmorespacetodocumentyourexperience.)

Employer Name and Address

Dates Employed

 

Class of

 

 

License Held

 

From:

To:

 

 

1.

2.

AND

I have a minimum of 18 months experience in the last 3 years while employed by a 19-A carrier in the operation of the type of vehicle

in which I will be testing. (Provide information about your employer(s) below. Attach a separate sheet if you need more space to document yourexperience.)

Employer Name and Address

Dates Employed

 

Class of

 

 

License Held

 

From:

To:

 

 

1.

2.

EDUCATION

In addition to the above experience, you MUST have completed one of the following courses. Check the box that applies to you.

o Ihavesuccessfullycompletedacollege-levelcoursewithaminimumof4credithoursindrivereducationinstruction. (Attachacopyofyourtranscript.)

OR

o IhavesuccessfullycompletedaDMV-approvedcourseindrivertrainingandtrafficsafetyfor19-ACertifiedExaminers. (Attachacopyofyourcoursecertificate.)

EXCEPTION

Youmaybeabletoprovidespecialaffidavitsifyoudonothaveaminimumof18monthsexperienceinthelast3yearswhileemployedbya 19-Acarrierintheoperationofthetypeofvehicleinwhichyouwillbetesting.Attachdocumentationoutliningyourexperienceandtraining andanyotherspecialcircumstancewhichmightqualifyyoutobecomeacertifiedexaminer.TheBusDriverUnitwillreviewyour informationanddeterminewhetheritisacceptable.

AFFIRMATION

IherebymakeapplicationtotestdriversinaccordancewiththemandatesofArticle19-AoftheNewYorkStateVehicleandTrafficLaw. To the best of my knowledge, the information provided is true and correct. I understand that any false statement I make on this application is punishableasamisdemeanorunderSection392oftheNewYorkStateVehicleandTrafficLaw.

Applicant’sSignature: _______________________________________________________________

Date: ____________________

 

 

CARRIER ENDORSEMENT

 

 

 

IendorsethisapplicanttobeaCertifiedExaminerformycompany.

 

Current19-AEmployerName(pleaseprint):__________________________________________________________________________

Current19-AEmployer’sSignature: ____________________________________________________

Date:_____________________

PAGE 2 OF 2