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The undersigned, a duly authorized peace officer of
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_______POLICE DEPARTMENT
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Hereby requests that a blood sample be obtained from
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Name of Person Being Tested______
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Driving Under the Influence
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I certify that I have probable cause to believe that the sample obtained will provide evidence that the person being tested was
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motor vehicle in violation of one or more of the following: California Vehicle Code 23152(a)(b)(c)(d)(e)(f)(g), 23153 or 23140.
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Date
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Time
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DR
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Badge or ID Number
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Signature of Peace Officer
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CONSENT FOR BLOOD TEST
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Consentimiento Para Someterse a un Analisis De Sangre
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I hereby consent to the withdrawal of a blood sample from my body. I certify that I am not a person who is afflicted
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with hemophiiia or a person who is afflicted with a heart condition and using an anticoagulant.
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Por la presente, consiento a qua se extralga de mi cuerpo una muestra de sangre. Certifico que no padezco de
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I hereby consent to the withdrawal of a blood sample from my body. I certify that I am not a person who is afflicted
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Date (fecha)
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Time (hora)
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Signature of person being tested (firma de persona someride al analisis)
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Witness (testigo)
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STATEMENT OF PERSON WITHDRAWING THE BLOOD
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Upon the request of the peace officer named above, I have withdrawn a blood sample from the above-named person on
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Date obtained
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Time obtained
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The blood sample was obtained from the______arm / hand / antecubital area.
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Area cleansed with
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Other area blood sample obtained from
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Name of Person Withdrawing Blood
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Title
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Signature of Person Withdrawing Blood
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