Form of declaration regarding withdrawal of sample of blood

NAC 50.055 Form of declaration regarding withdrawal of sample of blood. ( NRS 50.315 ) A declaration referred to in subsection 4 of NRS 50.315 must be in substantially the following form: I, ................., hereby declare: That I am a ................ (occupation) employed by ................ (employer); That a regular part of my duties is the withdrawing of blood samples from persons and I am authorized to do so by the ......................... (name of appropriate licensing or certifying agency); That on ......................... (date) at ..... o’clock ...m., I withdrew a sample of blood in a medically accepted manner from a person known to me as ................ (name); and That I kept the sample of blood in my sole custody or control and it remained in substantially the same condition as when I first obtained it until on ......................... (date) I delivered the sample to ................ (name of person) of the ................ (name of law enforcement agency). I declare under penalty of perjury that the foregoing is true and correct. Executed on ......................................... ............................................................................. (Date) (Declarant’s Signature) ............................................................................. (Declarant’s Title) (Added to NAC by Com. on Testing for Intoxication by R112-97, eff. 5-26-98)