EXHIBIT D

APPLICATION FOR BREATH TESTING INSTRUCTOR

ARIZONA DEPARTMENT OF PUBLIC SAFETY

Scientific Analysis Bureau 2102 W Encanto Blvd Phoenix, Arizona 85009

[phone]

Application for an Instructor certificate to provide Operator and QAS training 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 APPROVAL        

RENEWAL          

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

OPERATOR DEVICE(S) / PERMIT NUMBER(S)?                                                                                                                                            DO YOU HAVE QAS PERMIT(S)?   YES          NO           

QAS DEVICE(S) / PERMIT NUMBER(S)                                                                                                                                                        

1.        Name:                                                                                                                                                                                                            

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

Name:                                                                                                                                                                                                            

(As you want it to appear on certificate)                         (Last)                        (First)                           (Middle-optional)

2.        Employer:                                                                                                                                                                                                      

(Name)

3.        Email address:                                                                                                                                                                                                

4.        Instructor certificate requested for what device:                                                                                                                                                I hereby certify that the information submitted in this application is true and correct.

(Signature of Applicant)                                                                                  (Date)

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

TO BE COMPLETED BY REGULATOR

1.        Arizona Department of Public Safety examination approval number:                                                                                                             

2.        Did applicant successfully attain Instructor approval? Pass             Fail           

(Signature of Regulator)                                         (Print Name)                                                   (Date) DPS Form Exh D (Rev 05-1)

Historical Note

New Exhibit D 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