Applications & Forms

State Public Health Laboratory - Breath Alcohol

This page has the links to all the forms you may need to renew your Type I, Type II or Type III permits in addition to the maintenance report forms and operational checklists for the particular instrument that you are using in your jurisdiction.

You can click on the form names below and that will open the form in an Adobe Acrobat Format (.pdf). You can then download the form you have chosen and print them for your use.

Another way to download the form is to right-click on the link and then choose "Save Target As...", and then save the .pdf file to any location in your computer.

Permit Applications

Type 1 – laboratory persons who test for alcohol or drugs in blood, urine or saliva
Type 1 - fill-in form (form must be printed off and signed prior to submittal)

Type 2 – persons authorized to supervise the breath analyzer, perform preventative monthly maintenance not to exceed 35-days, train Type 3 operators and perform breath tests on specified evidential breath analyzer
Type 2 – fill-in form (form must be printed off and signed prior to submittal)

Type 3 – persons authorized to perform breath tests on an evidential breath analyzer
Type 3 – fill in form (form must be printed off and signed prior to submittal)

The fill-in forms may be saved to the local computer if using Adobe Acrobat Reader 8.0 or later.

Maintenance Report Forms

Alco-Sensor IV/RBT IV

Intoxilyzer 5000
Intoxilyzer 5000 – fill in form (form must be printed off and signed prior to submittal)

BAC DataMaster
BAC DataMaster – fill in form (form must be printed off and signed prior to submittal)

The fill-in forms may be saved to the local computer if using Adobe Acrobat Reader 8.0 or later.

Operational Checklists

Alco-Sensor IV/RBT IV
Intoxilyzer 5000
BAC DataMaster