22 CRR-NY D VI Form 5aNY-CRR

STATE COMPILATION OF CODES, RULES AND REGULATIONS OF THE STATE OF NEW YORK
TITLE 22. JUDICIARY
SUBTITLE D. FORMS
CHAPTER VI. FORMS FOR USE IN COURTS EXERCISING CRIMINAL JURISDICTION
22 CRR-NY D VI Form 5a
22 CRR-NY D VI Form 5a
5a Nav. L. chemical tests—order
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. § 491 ___________ 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)

Footnotes

1
Strike all items not applicable
22 CRR-NY D VI Form 5a
Current through May 31, 2021
End of Document