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DL-26 (3-12)

CHEMICAL TESTING WARNINGS AND REPORT OF REFUSAL TO

SUBMIT TO CHEMICAL TESTING AS AUTHORIZED BY SECTION

1613

OF THE VEHICLE CODE (COMMERCIAL MOTOR VEHICLE)

Side 2

NAME

SEX

D A T E O F B I R T H

FIRST

MIDDLE

LAST

MONTH

DAY

YEAR

ADDRESS:

CITY

STATE

ZIP CODE

A P.O. Box number may be used in addition to the actual residence address, but cannot be used as the only address.

DRIVER NUMBER

STATE

CHEM TEST REQUEST DATE

SOCIAL SECURITY NUMBER

CDL Holder

MONTH

DAY

YEAR

o YES

o NO

Was a CMV Being Driven: __________ (Check if applicable)

Were Hazardous Materials Being Carried: __________ (Check if applicable)

SECTION 1613 - CHEMICAL TESTING WARNINGS

It is my duty as a police officer to inform you of the following:

1. I am requesting that you submit to a chemical test of ______________________ (blood, breath or urine. Officer chooses the chemical test).

2. Because you were operating a commercial motor vehicle, if you refuse to submit to the chemical test your commercial driving privilege will be disqualified

for at least one year, and it could be disqualified for life. In addition, if you are arrested for driving under the influence of alcohol or a controlled substance

in violation of Section 3802 of the Vehicle Code and you refuse chemical testing, your operating privilege will be suspended for at least 12 months. If you

previously refused a chemical test or were previously convicted of driving under the influence, your operating privilege will be suspended for up to 18 months.

In addition, if you refuse to submit to the chemical test, and you are convicted of violating Section 3802(a)(1) (relating to impaired driving) of the Vehicle

Code, then, because of your refusal, you will be subject to more severe penalties set forth in Section 3804(c) (relating to penalties) of the Vehicle Code.

These are the same penalties that would be imposed if you were convicted of driving with the highest rate of alcohol, which include a minimum of

72 consecutive hours in jail and a minimum fine of $1,000.00, up to a maximum of five years in jail and a maximum fine of $10,000.

3. You have no right to speak with an attorney or anyone else before deciding whether to submit to testing. If you request to speak with an attorney or anyone

else after being provided these warnings or you remain silent when asked to submit to chemical testing, you will have refused the test.

I certify that I have READ the above warning to the operator regarding the disqualification of his/her operating privilege and gave the operator an

opportunity to submit to chemical testing.

Signature of Officer: _____________________________________________________

Date:__________________________

I have been advised of the above.

Signature of Operator:____________________________________________________

Date:__________________________

Operator refused to sign, after being advised.

Signature of Officer: ______________________________________________________

Date:__________________________

NOTE TO OFFICER: The refusal of the operator to sign this form is not a refusal to submit to the chemical test. You must still give the operator an

opportunity to take the chemical test after reading this form to the operator.

AFFIDAVIT

1. The above commercial motor vehicle driver was stopped by a police officer who, after stopping the driver, had reasonable grounds to believe that the driver

had been operating a commercial motor vehicle while having any alcohol in his/her system.

2. The above commercial driver was requested to submit to chemical testing as authorized by Section 1613 of the Vehicle Code.

3. The above commercial driver was read by a police officer the chemical test warnings contained in paragraph 2 and 3 above.

4. The above named commercial driver refused to submit to chemical testing after having been read the above warnings.

I certify that all information given in this form is true and correct:

Officer Signature: _____________________________________________________________________________________________________________

Officer Name: ________________________________________________________________________________________________________________

Badge Number: _____________________Jurisdiction: ________________________________________________________________________________

Mailing Address _______________________________________________________________________________________________________________

__________________________________________________________________ Phone: ( _______) _________________________________________

PLEASE LIST NAME, BADGE NUMBER, AND PHONE NUMBER OF ARRESTING OFFICER IF NOT THE SAME OFFICER WHO WITNESSED

THE REFUSAL: ________________________________________________________________________________________________________

Note: Any pertinent facts not covered by the affidavit should be submitted on a separate sheet and attached hereto. That sheet should include the

names of additional witnesses necessary to prove the elements to which you have attested.

Forward to: Department of Transportation

Bureau of Driver Licensing

P.O. Box 60037

Harrisburg PA 17106-0037

THIS FORM MAY BE DUPLICATED

Dl-26 - Chemical Testing Warnings And Report Of Refusal To Submit To Chemical Testing As Authorized By Section 1547 Of The Vehicle Code In Violation Section - Pennsylvania Department Of Transportation Page 2

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