United States

United States

Phone: 1-516-826-4040
Fax: 1-516-826-0711

Phone: 1-516-826-4040
Fax: 1-516-826-0711

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NYS DOT Bus Inspection MC19 1b

Please Fill in the Following Information

* Operation Information

Oper Id: *   Type Oper: *  
Number of Vehicles: *  
Company : *  
Address: *  
City: *      
State: *      
Zip Code:    
Phone#: *   Ext:
Fax :    

Inspection Information

Location : *  
Address: *  
City: *   State: *   Zip Code:
Phone#: *   Ext: Fax:
Manager: *          

Adequate Facility     Pit     Lift     Phone     Electric Desk     Other
Does the manager have a copy of the current out of service criteria? Yes No

Yes, please send NYSDOT information via e-mail to the following address:
Name: *   E-Mail Address: *  
Name: *    E-Mail Address: *

INSPECTION NOTIFICATION INFORMATION
Motor Vehicles shall be presented for inspection at the time and place designated by a duly authorized representative Department. The following individual(s) is/are responsible to insure that any required records and vehicle(s) are available Inspection:

Name: *   E-Mail Address: *  
Name: *    E-Mail Address: *

ACCIDENT/INCIDENT NOTIFICATION INFORMATION
The following individuals are familiar with the requirements as contained in NYCRR Title 17 Part 722 and are primarily responsible to report accidents/incidents to the NYDOT.

Name: *   Tel. No:
Name: *    Tel. No

Prepared by: *    Date:
  Motor Vehicle Inspector    

DULY AUTHORIZED COMPANY REPRESENTATIVE CERTIFICATION:
I am a duly authorized representative of the organization as indicated above. I reviewed the information on this form and to the best of my knowledge find it to be true and accurate.

Name: *   Title.:

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