Get NY DS-872 2015-2024

DS-872 6/15 CARRIER S ANNUAL REVIEW OF EMPLOYEE s DRIVING RECORD UNDER ARTICLE 19-A DRIVER INFORMATION First Driver s Last Name M. I. Street Address Date of Birth Month/Day/Year City Client/License ID Number from Driver License State Class of Driver s License Endorsements Zip Code Restrictions Expiration Date CARRIER INFORMATION Carrier/DBA Name Legal Name if different Federal ID Number Were you involved in ANY motor vehicle accident s during the past 12 months o YES Information section below ACCIDENT INFORMATION if additional space is needed use the back of this form Date of Accident Location City State Zip Code County 19-A Business ID Number o NO Briefly describe property damage type of vehicle involved and approximate dollar value of damage for each vehicle If YES complete Accident Number of People Injured Were you convicted of ANY traffic violation s other than parking or any crime s during the past 12 months Were there any fatalities YES or NO o YES RECORD OF CONVICTIONS if additional space is needed use the back of this form Date of Violation Conviction Of What Charge Type of Motor Vehicle Operated o Court Location CMV 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. - Driver Signature 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 ABSTRACT S WHICH MUST BE DATED WITHIN 30 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 Authorized Signature of Carrier Representative www. dmv*ny. I. Street Address Date of Birth Month/Day/Year City Client/License ID Number from Driver License State Class of Driver s License Endorsements Zip Code Restrictions Expiration Date CARRIER INFORMATION Carrier/DBA Name Legal Name if different Federal ID Number Were you involved in ANY motor vehicle accident s during the past 12 months o YES Information section below ACCIDENT INFORMATION if additional space is needed use the back of this form Date of Accident Location City State Zip Code County 19-A Business ID Number o NO Briefly describe property damage type of vehicle involved and approximate dollar value of damage for each vehicle If YES complete Accident Number of People Injured Were you convicted of ANY traffic violation s other than parking or any crime s during the past 12 months Were there any fatalities YES or NO o YES RECORD OF CONVICTIONS if additional space is needed use the back of this form Date of Violation Conviction Of What Charge Type of Motor Vehicle Operated o Court Location CMV 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. .