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The undersigned, a duly authorized peace officer of
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Name of Law Enforcement Agency
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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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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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driving a motor vehicle in violation of California Vehicle Code 23152(a) (b) (e) (f), 23153 or 23140.
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Date
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Time
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Badge or ID Number
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Signature of Peace Officer
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BLOOD DRAW SEARCH WARRANT INFORMATION
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Search Warrant Number
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Issuing Magistrate
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Name of Affiant
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Date and Time Warrant Issued
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Date and Time Warrant Executed
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Place Where Warrant Was Executed
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Witness(s)
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STATEMENT OF PERSON WITHDRAWING THE BLOOD
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Upon the request of the peace officer(s) named above, I have withdrawn a blood sample from the above named person
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(1) This warrant was duly executed as specified above and in accordance with the terms of the warrant.
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(2) The blood sample that was drawn was duly sealed and will be promptly submitted to an approved laboratory for the
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purpose of determining its alcohol and/or drug content.
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Date Obtained
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Time Obtained
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The blood sample was obtained from the______arm.
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Signature of Person Withdrawing Blood
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Title
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ID Number
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