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" . ,. '.', , ":...;;:. .'...... " DI." 14111 CH.M1OA~ TilTING WAAHINoI'~No RIPORr ollO" ';II Ill;'" 11\ A.PUIA.!. TO SUBMIT TO CHIUICA1. TellTlNQ~P , ' iCI AUTHORIZI!D BY OP THE VEHICLe CODe . ','. "~I' ,- " ~ll:\; flOll' I ~1.lI HAIlI ~IAIIT au /)') ADDIlIII CITY d;) LI ((IE. DAIVU HUIIIlA ~ ~ lTATI . I, P1H';;lii~1IiIt~... now under""," fat dtlvillg lIllolIr Ill; InftutNlOe oI.Ioohol';~ ....oaId .~." !h. V.hlcle Code, 211m requ"ling th.t yau lubmlllo II ch.mlcall.., 01 j,LcO\) (b,...1h. ~ood Of ""riIW OHicer chooIMatw cheaClIJ ..., 3 1111 my duty, "' police offlcar. 10 Inlorm you lhalll you IOIUlllo lubmlllo Ute ch,mlcallft'your opo,.tinO privttege wlft be 'lUependId tor. p."od 01 on. y.at . 0) Th. contliMional right' you hIve I" criminal dol.ndlnr, commonly Mown II the ....rand. Rlghtl,lncluchno the nghl to ~ak Wlch....,.. and Ihl nghllV ramaln .i1lnl. apply only 10 criminal prolGCUllon. Ind do nOI apply to Ih. chemical "'~ng procedure un6ft PettntyIYMW. tmp"-d Con.."1 Law. whioh II . dn, nolI c:nmlnal ptoceedWlg. D) You h... no rlgh'lO.peoll to .IIrwpf, or .nyOlMl 01.., boIoro 'Ulft(l1l1o c:homo:.'IO,'roqu"1Od by 1110 polioo _ nor do ,.... ho...r1ghIlo remOln .1I.n, when ..~od D~!ho pollC' 01_" .ubmn 10lhe chomlclllO'L Unlo.. you .gro.1O ,uDm'I'Olho lOll roque..... by tho,,- ottloor your conducl will be eMlmld 10 bl '11u..1 and your oplrlbng PlIW~.ga W1U b, .u.pendld tor one .",,,. c) Your 'Itul.11G lubmU to chemical telling under ",.Implled Conlin. law may b. Inltoduced mlo evOlnce In OJ cnminal proaacut:lon lor Q1vtng wh'. undor tho Inllu.nco 01 oIcohol Of . conltanod .ub.II.00, , &he., oper.llng pn'itktg. and ga.,. rhe "",lOrtlllII oppcI$I. _,__ 0.1. y- 2/ -f' il..2JIPS. 0." _fi"tt/11; '.'\ '. Mo10nll ,,'uIlId 10 IIgn, It'lr bllng fldVII.d Signalur. 0' Olllccr _.__~~.. ,'0 ~ ~. .''0' I." \~"_~ :'" H' Olio .:tt A",DA VIT , Thl .bOWI' molarl.1 WI" plllcad u"dr.r 'UlII'1 'or drlYlng undor Ih. '""",.no. ol.ahal 01 . oonlrolod lublWI\OI V\ wtO"lIon oI8ed1on a731 Df" V.hles.. elide. and rhor. wor.. 1I11.0n.blD groundl fo boll.v. ""1 1M .bow motollll "ad bHn dfM"9. OJWflbng or In 8CtuaJ phy.a. OGritrol 0' Ihl movDm.nl 01. motor vohtclo whil. under tho Innuencl olllcohol or. contnJlIlNllubl'lnoe or boltl 01 Thllth. above namld motorlll WII I"VOIVCId In ." leadenlln whICh Ihl operlJot' 01 p8111f1llUr of an,. v.hdllnvol.,1d 0' . pldl.tnan requtrwd Itllrmont at a ",*~'llaclllty or .11 killed 2: T". _1lIll1llft1l..... tt<lWI,td ra tlIb1nn ra cl>ItllIooI..\Iflo;J n .ulha~rtd by _on 15410' tl>o V.hld. Code 3, T". .b_ mallll1.1 *..,.10"".. by "01100 oHlcor ollft. _"'101' .....,Itlg. con\llned In p,,"_h 3 .nd . .bow .. Th. lboWl nlmed motorl.1 re'uled 10 lubmlllo chlmlClII.lllng OFPICI!R NOT!! Th. rofullllo .Ign Ihl. form II nOI' ,.IUII'IO lubmll fa Ih.c......IClII..t. You mUII.UII glv. the motortltart oppoftu- nil, 10 till. Ihl cheml~II'11 .11.,. reviewing Ihl. form. It 'h.lndlvtdul'." operltlng I commerclll molar el. whIte hawlftg ear .Icohol Dr I canaroUed aub.t.ne,'n Ihti, Iy.t.m. you mUll 1110 OOft'ipMl' Ih'~""" .Jet. ollh form. '....t(.AlaHI~f)'...,""-,; . Oftl:'" Sognatu'o tij._ rnlll.t)'lofWl- ,.....~. .~., '~',I"" , ~,'k ,"'/.1 i;l:;......... -o"'m~'''' in.!>' ,!!E'V~'~ 5 JH1Jl~ I 11~.rl." i eo09O u"",.... .! (I,! _ JUI;.d,ellon .!{~11IPL'tL ,wf Plio... (.J.I",L}H:_;J~.u7 .....IIft(l Add,... jj 3 0 _~.tuJlJ.!~, Il,l.L {2 ~ M'(II~Nill!!!!ti... PA po JT '. Farwlrd to: C.partm.nl 0' Trl..paU.',on Bur..u of Drlv.r llc.n.lng P.O, Ba. 60037 Hlrrl8burg, PA 17t06,0037 .,.! '. 11419 FORM MAY BIl DUPLICATED " , , ., il-';;.. NOli' Atry ,,",lIftonll.en nOlocmrod by 111. .tl1dawtl alloulr;t tlll,~~.:;;' .optr.1I "'Oft ..d .n.dlod ~oralo, That .heIl ahallrd r.c;udo''N:\iiiiQii:l1l~; . eddi1lo<lol '"""..... __...", 10 prove I'" .w.-u III wIlkiIl.......... U.l;'~' ADOITra/Al SUPPLIES OF THIS FOR'" my DE 6Wl1lllio'lI1'~'i1ft/i~';~ , , ',',',.. ,1;';;,"((' " .~.~~..... .