Form Ds-622 - Article 19-A Complaint Form Page 2
Download a blank fillable Form Ds-622 - Article 19-A Complaint Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Ds-622 - Article 19-A Complaint Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2SECTION 3 - COMPLAINT AGAINST MOTOR CARRIER OR CERTIFIED EXAMINER
Please be as specific as possible about the problem or complaint and the date(s) of the incident(s). If you have any supporting
documentation (e.g. a fraudulent form) please submit it with your complaint.
Motor Carrier’s Name
Address
City
State
Zip Code
AND/OR
Certified Examiner’s Name
Certified Examiner #
Associated Motor Carrier
COMPLAINT: (attach additional pages if necessary)
* I ACKNOWLEDGE AND UNDERSTAND THE FOLLOWING:
If this complaint results in a hearing, this complaint and supporting documentation provided can be used as evidence.
l
DMV is permitted to provide this complaint and supporting documentation to the motor carrier or certified examiner named as the
l
subject of this complaint.
This complaint and supporting documentation may be made available in response to a Freedom of Information (FOIL) request.
l
-
Signature
Date
RESET/CLEAR
DS-622 (10/16)
PAGE 2 OF 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal