EXHIBIT C

APPLICATION FOR BREATH ALCOHOL QUALITY ASSURANCE SPECIALIST PERMIT

ARIZONA DEPARTMENT OF PUBLIC SAFETY

Scientific Analysis Bureau 2102 W Encanto Blvd Phoenix, Arizona 85009

[phone]

Application for a QAS permit to perform quality assurance procedures on an approved device.

DO NOT WRITE IN THIS AREA

Permit #                                    Date issued                        Approved by                       

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          

DO YOU HAVE AN OPERATOR PERMIT(S)?  YES         NO           

OPERATOR DEVICE(S) / PERMIT NUMBER(S)                                                                                                                     

1.        Name:                                                                                                                                                                                                            

(Full Legal Name)                      (Last)                              (First)                        (Middle)                      (Maiden)

Name:                                                                                                                                                                                                            

(As you want it to appear on permit)                              (Last)                        (First)                           (Middle – optional)

2.        Employer:                                                                                                                                                                                                      

(Name)

(Address)

3.        Email address:                                                                                                                                                                                                

4.        QAS permit requested for what device(s):                                                                                                                                                       I hereby certify that the information submitted in this application is true and correct.

(Signature of Applicant)                                  Badge #                                                   (Date)

* * * * * * * * * * * * * * * * * * *

TO BE COMPLETED BY INSTRUCTOR

1.        Agency Conducting Training:                                                                                                                                                                         

2.        Date and Location of Training:                                                                                                                                                                      

(Date)                                               (Location)

3.        Arizona Department of Public Safety course approval number:                                                                                                                    

4.        Did applicant successfully complete the course?  Pass             Fail           

(Signature of Instructor)                                         (Print Name)                                                   (Date) DPS Form Exh C (Rev 05-1)

Historical Note

New Exhibit C 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