New York Codes, Rules and Regulations
Title 22 - JUDICIARY
Subtitle D - Forms
Chapter VI - Forms For Use In Courts Exercising Criminal Jurisdiction
Form 5a - Nav. L. chemical tests-order

Current through Register Vol. 45, No. 52, December 27, 2023

Sec. 49 Nav. L. Form 5A

(Nav. L. Chemical

Tests - Order)


________ 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


________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.


____________, New York


Date: ____________, 19 ________

Time: ____________ [a.m.] [p.m.]


Judge [Justice]


Applicant (if order issued orally)

[FN1] Strike all items not applicable

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