Nev. Admin. Code § 50.025
A declaration which is referred to in subsection 1 of NRS 50.315 must be in substantially the following form:
I, ..........................................., hereby declare:
That I am ................ (occupation) employed by ............. (employer);
That I was certified on ......................... (date) by the Director of the Department of Public Safety as being competent to operate a ................ (name of breath-testing device), a device of a type which, as designed and manufactured, has been certified by the Committee on Testing for Intoxication to be accurate and reliable for testing a person's breath to determine the concentration of alcohol in his or her breath;
That on ......................... (date) I obtained a sample of the breath of ................ (name of person tested) and tested it in accordance with the prescribed checklist on a ................ (name of device) which was functioning properly; and
That the tests indicated the breath of the person tested contained the following concentrations of alcohol (grams per 210 liters of breath):
1st test ... 2nd test ... 3rd test ...
I declare under penalty of perjury that the foregoing is true and correct.
Executed on ......................................... .............................................................................
(Date) (Declarant's Signature)
.............................................................................
(Declarant's Title)
Nev. Admin. Code § 50.025
NRS 50.315