The State [City] satisfies its burden of proof if the evidence shows, beyond a reasonable doubt, the following essential elements of the offense charged:
1. On or about _______________, 19__, the Defendant, __________________, was in actual physical control of a vehicle in ______________ County [City], North Dakota, on a highway [street] [or on public or private areas to which the public has a right of access for vehicular use]; and,
2. Any of the following:
a. The Defendant had an alcohol concentration of at least then one-hundredths of one percent by weight at the time of the performance of a chemical test within two hours after being in actual physical control of the vehicle.
b. The Defendant was under the influence of intoxicating liquor.
[c. The Defendant was under the influence of any drug or substance or combination of drugs or substances to a degree which renders that person incapable of safely driving.]
[d. The Defendant was under the combined influence of alcohol and any other drugs or substances to a degree which renders that person incapable of safely driving.]
NOTE: Subparts [c] and [d] are to be used if pertinent to the charge.