N.Y. Comp. Codes R. & Regs. tit. 22, subtit. D, ch. VI, form 5a
Sec. 49 Nav. L. Form 5A
(Nav. L. Chemical
Tests - Order)
9/89
________ Court of ________
County of ________
________ x
In the Matter of the Application of
________, Indictment/Docket
[name of applicant] No. ________
for an order to compel ORDER COMPELLING
SUBMISSION TO A
________to CHEMICAL TEST
[name of arrestee]
submit to a chemical test, pursuant to Nav. L. § 49[FN1]
________ x
Upon the application [affidavit] of ____________sworn to [dated] ________, 19 ________,
[name of applicant]
for an order pursuant to section 49 of the Navigation Law to require ____________to submit
[name of arrestee]
to a chemical test, and sufficient reason appearing therefor, it is
ORDERED that the arrestee submit to a chemical test of the alcoholic or drug content of his/her blood, and it is further
ORDERED that a person authorized pursuant to section 49 (4)(e)(1) of the Navigation Law, em-
ployed at ____________ withdraw a proper amount of blood from the arrestee, for the purpose of
[name of facility]
conducting such chemical test.
E N T E R
____________, New York
[location]
Date: ____________, 19 ________
Time: ____________ [a.m.] [p.m.]
______________
Judge [Justice]
______________
Applicant (if order issued orally)
[FN1] Strike all items not applicable
N.Y. Comp. Codes R. & Regs. tit. 22, subtit. D, ch. VI, form 5a