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Driver Program Regulation Complaint Form. This is a New York form and can be use in Department Of Motor Vehicles Statewide.
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Tags: Driver Program Regulation Complaint Form, DPR-201, New York Statewide, Department Of Motor Vehicles
DPR-201 (4/11)
New York State Department of Motor Vehicles
DRIVER TRAINING PROGRAMS
COMPLAINT FORM
www.dmv.ny.gov
OFFICE USE ONLY
BUSINESS ID #
CLIENT ID #
Please print clearly.
COMPLAINT TYPE
The type of business or individual you have a complaint about is:
BUSINESS
INDIVIDUAL
o Alcoholism Evaluation/
o Alcoholism Evaluation/
o
o
o
o
o
o
o
Treatment Provider/Facility
o
o
o
o
Bus Carrier
Drinking Driver Program
Driver Education Program
Driving School
o Driving School Instructor
o Point/Insurance Reduction
Treatment Counselor
Article 19-A Certified Examiner
Bus Driver
Drinking Driver Program Instructor
Driver Education Instructor
o
o
Program Instructor
Pre-licensing Instructor
Other ____________________
________________________
Point/Insurance Reduction Program Delivery
Agency
Point/Insurance Reduction Program Sponsor
Other:_______________________________
SUBJECT OF COMPLAINT
Your complaint is against:
Business Name
Individual’s Last Name
Individual’s First Name
M.I.
Suffix
Address
Address
City
State
Zip Code
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PERSON/BUSINESS FILING COMPLAINT
Your Last Name
DPR-201 (4/11)
Your First Name
M.I.
Suffix
Your Address
Address
City
State
Zip Code
Home Phone
(
)
Work Phone
(
)
E-mail Address
Business Name
DESCRIPTION OF COMPLAINT
On what date(s) did the incident occur?_________________________________________________________________
Please describe the complaint in detail. Attach additional pages if necessary.
Are you willing to appear and testify at a hearing if one is held to resolve this complaint?
o Yes o No
Be sure to attach COPIES of any supporting correspondence and/or documents.
I understand that a copy of this form and any or all of the enclosed information may be shared with the business or individual on
page one of this form if a hearing is held to resolve this complaint. In addition, I understand that the complaint may be disclosed if
it is the subject of a subpoena or Freedom of Information request, and that DMV will not disclose the complainant’s personal
information, other than name, unless compelled to do so by a subpoena or court order.
Your Signature
ç
Date
Please complete and mail or fax this original document
with all necessary attachments to:
New York State Department of Motor Vehicles
Driver Training Programs
6 Empire State Plaza, Room 412
Albany NY 12228
Fax: (518) 473-0160
OFFICE USE ONLY
Complaint Number
PAGE 2 OF 2
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