Form Ds-870 - Article 19-A Bus Driver Application
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DS-870 (11/17)
ARTICLE 19-A BUS DRIVER APPLICATION
(Complete all parts of this form. Please print or type.
Send original to Bus Driver Unit, keep a copy in your driver 19-A file.)
DRIVER INFORMATION
Driver’s Last Name
First
M.I.
Date of Birth (Month/Day/Year)
Social Security Number
Male
Female
Street Address
City
State
Zip Code
County
Telephone Number
Class of Driver’s License Endorsements
Restrictions
Expiration Date
License ID Number
State
(from Driver License)
CARRIER INFORMATION
Carrier/DBA Name
Legal Name (if different)
Federal ID Number
19-A Business ID Number
Street Address
City
State
Zip Code
County
Telephone Number
Name of Article 19-A Contact Person
Title
Is this employer/carrier a school bus carrier?
Yes
No
ADDITIONAL DRIVER INFORMATION
Provide your employment, accident, and conviction history and answer the questions below. If necessary, attach additional pages.
1. Have you qualified as a school bus driver under ARTICLE 19-A?
Yes
No If “yes”, give month and year of qualification
2. Are you a certified ARTICLE 19-A examiner?
Yes
No
If “yes”, give certificate number
and expiration date
.
EMPLOYMENT (Start with your most recent employment, and include work
What were the date(s)
of your employment?
history for the past 3 years):
(From - To)
Employer Name and Address
Your job title
ACCIDENTS (Start with your most recent accident, and include accidents within the past 3 years):
Was there personal injury or property damage?
Location
If “YES”, indicate the dollar amount of damage to each
Date of Accident
(City, State, Zip Code, County)
What type of vehicle were you driving?
vehicle, and the number of people injured.
CONVICTIONS (Start with your most recent conviction, and include all criminal convictions):
Location
If a vehicle was involved, what type
Date of Violation
(City, State, Zip Code, County)
Date of Conviction
Of what charge were you convicted?
of vehicle were you driving?
DRIVER AFFIRMATION: To the best of my knowledge, the information I have given on this application is true.
X
Date
Signature of Driver
EMPLOYER CERTIFICATION: This application has been reviewed together with the driver abstract and medical examination (form DS-874 or
USDOT form 649-F or equivalent) and the applicant is hereby classified as a “conditional driver” as defined in Section 6.2(r) and in accordance
with the requirements of Sections 6.3 and 6.4 of the regulations of the Commissioner of Motor Vehicles. Final approval of employment is subject
to the applicant meeting the requirements of Article 19-A of the New York State Vehicle and Traffic Law. All questions pertaining to this form and/or
the Article 19-A Program should be directed to: New York State Department of Motor Vehicles, Bus Driver Unit, 6 Empire State Plaza, Rm 136B,
Albany NY 12228, (518) 473-9455.
X
Date
Signature of Employer/Agent
dmv.ny.gov
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