IMPLIED CONSENT ADVISORY
(Effective May 28, 2003)
_______________________________________________, I believe you have been carrying a pistol on or
about your person or clothing in a public place in violation of Minnesota’s firearms laws and you have been
placed under arrest for this offense, or you have been involved while carrying a firearm in a firearm related
accident resulting in property damage, personal injury, or death, or you have refused to take a preliminary
screening test or the test was administered and indicated an alcohol concentration of 0.04 or more.
________ 1. Minnesota law requires you to take a test to determine:
(Check applicable portion when read)
______ a. if you are under the influence of alcohol.
______ b. if you are under the influence of hazardous or controlled substances.
________ 2. Refusal to take a test may result in a civil penalty of $500 and revocation of your permit
(Check when to carry a pistol for a period of one year from the date of refusal.
________ 3. Because I have probable cause to believe you are impaired by a controlled substance that
(Check when is not subject to testing by breath, a blood or urine test is being required of you.
_______ 4. (READ ONLY IF PROBABLE CAUSE TO BELIEVE VIOLATION OF
(Check when CRIMINAL HOMICIDE, ASSAULT LAWS, MINN. STAT. § 609.66, OR OTHER
CRIME FOR WHICH INVOLUNTARY TESTING BASED UPON PROBABLE
CAUSE IS PERMITTED.)
Because I also have probable cause to believe you have violated the criminal homicide or
injury laws, a test will be taken with or without your consent.
_______ 5. Before making your decision about testing, you have the right to consult with an
(Check when attorney. If you wish to do so, a telephone will be made available to you. If you are unable
to contact an attorney, you must make the decision on your own. You must make your
decision within a reasonable period of time.
_______ 6. If the test is unreasonably delayed or if you refuse to make a decision, you will be
(Check when considered to have refused the test.
Do you understand what I have just explained? _____ Do you wish to consult with an attorney? ______
Time telephone made available: Start: ___________ Stopped: ________________
Will you take the (Breath) (Blood or Urine) test? ______________
(If person refuses:)
What is your reason for refusing? _____________________________________________________________
Name of Officer:_____________________________Time Completed: ________Date: __________________