Submission Method In Person Drop Box Mail/Certified
Other
DPS Laboratory Use Only DPS Laboratory Case #
Complete the following for in person submissions only:
Printed Name (of submitting individual)	Agency
Signature	Date

New Service Request

Additional Evidence	Resubmission	Corrected Copy

DPS Lab Case # (if known)
Submission Information
Agency
Agency Case #
Offense	Felony
Offense Date	Offense Time
Offense County
Agency Contact Information
Title / Badge #

Full Name
Agency Address	City, State, Zip
Mark if new address
Business Email	Phone	Fax
Contact Info for Additional Report Distribution:

Service Requested

ONLY Alcohol/Volatiles Analysis (Submit to Service Area Laboratory)	ONLY Drug Analysis (Submit to Austin Regional Laboratory)	BOTH Alcohol/Volatiles and Drug Analysis (Submit to Service Area Laboratory)

Individual (S = Suspect, V = Victim) / Specimen Information

Name (Last, First, Middle, Suffix)	S / V	Race	Sex	DOB	State	Driver License #	ID Card #
Select all that apply: Driver Non-Driver	Living Deceased	Fatality Incident (Other than Suspect) Driving Commercial Vehicle	Child Passenger(s) Driver Under 21
Specimen Type: Blood Urine	Specimen Collection:
Date	Facility
Time	Collector

Additional Case Information

Intoxilyzer Results:	List Suspected Drug(s):
PBT Results:
Intoxilyzer Refused
DRE (Drug Recognition Expert) Exam Administered
Case Synopsis: (attach or include any other relevant case information)