Nev. Admin. Code § 50.045
A declaration referred to in subsection 3 of NRS 50.315 must be in substantially the following form:
I, ..........................................., hereby declare:
That I am a forensic analyst of alcohol employed by ................ (name of employer);
That I was certified by the Director of the Department of Public Safety on ......................... (date) as a person competent to calibrate evidential breath-testing devices;
That on ......................... (date) I calibrated a ................ (name of device) bearing serial number ........ which is located at the ................ (name of law enforcement agency) in ................ (city or county), Nevada;
That the ................ (name of device) is certified by the Committee on Testing for Intoxication, as designed and manufactured, to be accurate and reliable for the purpose of testing a person's breath to determine the concentration of alcohol in the person's breath (grams per 210 liters of breath);
That the calibration was performed by verifying the response and accuracy of the device, as prescribed in the regulations of the Committee on Testing for Intoxication, by ................ (description of procedure used);
That the calibration was performed within the period required and that the device was otherwise maintained as required by the regulations of the Committee on Testing for Intoxication; and
That upon completion of the calibration the ................ (name and serial number of device) was operating properly.
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 § 50.045
NRS 50.315