EXHIBIT A

APPLICATION FOR BLOOD ALCOHOL ANALYST PERMIT

ARIZONA DEPARTMENT OF PUBLIC SAFETY

Scientific Analysis Bureau 2102 W Encanto Blvd Phoenix, Arizona 85009

[phone]

DO NOT WRITE IN THIS AREA

Permit #                                    Date issued                                  Approved by                        

Application for Analyst permit to perform analysis of blood or other bodily substances for alcohol concentration determinations.

TO BE COMPLETED BY APPLICANT - PLEASE PRINT CLEARLY

(ALL ITEMS MUST BE COMPLETED OR APPLICATION WILL NOT BE ACCEPTED)

IS THIS APPLICATION FOR?   INITIAL PERMIT         

RENEWAL        

PERMIT NUMBER                                 

1.        Name:                                            

(Full legal name)                              (Last)                                        (First)                        (Middle)                      (Maiden)

Name:                                                                                                                                                                                                            

(As you would like it to appear on permit)             (Last)                 (First)                           (Middle - optional)

2.        Date of Birth:                                                                                                                                                                                                    (Month)                                     (Day)                                   (Year)

3.        Employer:                                                                                                                                                                                                      

(Name)

4.        Email address:                                                                                                                                                                                                

5.        Education: I have earned a degree from an accredited college or university with 15 or more semester credits or the equivalent of college chemistry, including at least 3 credits in organic chemistry. Yes             No           

College(s) attended                                                                                                                                                                                            (City & State)                           (Year Graduated)                    (Degree)

(City & State)                          (Year Graduated)                    (Degree)

6.        Check the analytical method(s) for which you require an Analyst permit:

Gas Chromatography                           

Other:                                                                                                                                           

I hereby certify that the information submitted in this application is true and correct.

(Signature of Applicant)                                                                          (Date)

DPS Form Exh A (Rev 05-1)

Historical Note

New Exhibit A made by final rulemaking at 12 A.A.R. 1916, effective 9:00 a.m., May 18, 2006 (Supp. 06-2).

Department of Public Safety - Alcohol Testing