EXHIBIT B
APPLICATION FOR BREATH ALCOHOL OPERATOR PERMIT
ARIZONA DEPARTMENT OF PUBLIC SAFETY
Scientific Analysis Bureau
2102 W Encanto Blvd
Phoenix, Arizona 85009
(602) 223-2394
Application for an Operator permit to perform alcohol concentration determinations and associated quality assurance
procedures on an approved device.
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)
________________________________________________________________________________________
(Phone) (Fax)
3. Email address:_____________________________________________________________________________________
4. Operator 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 B (Rev 05-1)
DO NOT WRITE
IN THIS AREA
Permit #
Date issued
Approved by
Arizona Department of Public Safety
