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Full Name:

Company:

Home Address:

*City:

State:

Zip:

Home Phone:

Cell Phone:

Work Phone:

*E-mail Address:

Are you interested in fighting your case for the best result possible? Yes Don't Know No

Date of Arrest:

Time of Arrest:

Town/Municipality Where Arrested Occurred:

*State of Arrest: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

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Day of Week:

Court Date:

Time of Court:

Place of Court:

Street or location where you were stopped:

Was there a breath test taken on the scene? Yes Don't Know No

     Result:

Was there a breath test at the police station? Yes Don't Know No

     Result:

Was there a blood test taken? Yes Don't Know No

     Result:

Is this your first arrest for DUI/DWI/Drunk Driving in your lifetime-anywhere? Yes Don't Know No

Please list all prior DUI/DWI/Drunk Driving Arrests (even if dismissed) below, including year, city/state, and outcome (if known):

Are you currently on probation/parole for any DUI or criminal case? Yes Don't Know No

     If "yes", for what offense(s):

Other tickets/Charges received with your present DUI Charge:

      Improper Lane Usage
      Speeding
      Red Light/Stop Sign Violation
      No Insurance
      Accident
      No Headlights
      Equipment Violation
      No Seat Belt
     Other:
     

Why were you stopped according to the police officer?

Was there an accident? Yes Don't Know No

Was anyone injured? (Check all that apply):

      No one was hurt
      Myself
      Passenger in my vehicle
      Passenger in another vehicle
      Pedestrian
      Not Sure

Were you stopped at a roadblock? Yes Don't Know No

Were you given field sobriety tests at the scene, hospital or police station? Yes Don't Know No

Which tests were you given? (Check all that apply):

      Portable Breath Test at scene
      Eye Test (also known as Horizontal Gaze Nystagmus
      Walk the Line
      Finger to nose
      Counting
      Alphabet
      Stand on one leg
     Other:
     

Did any police tell you that the tests were optional (you could refuse)? Yes Don't Know No

Were you videotaped at the scene or police station? Yes Don't Know No

Do you want to challenge the possible suspension of your drivers license? Yes Don't Know No

Do you need driving privileges for (check all that apply):

      Work
      School
      Medical care
      Transporting your children
      Personal errands

At any time did the police tell you that (check all that apply):

      Your have the right to remain silent
      You have the right to an attorney of your choosing
      If you cannot afford an attorney, one will be appointed for you
      Anything you say will be held against you in court
      You can stop talking at any time

Did you ever tell the police that you wanted to speak to an attorney? Yes Don't Know No

Did you ever ask for an independent test of your own? Yes Don't Know No

Is it possible that there was drugs/medications in your system? Yes Don't Know No

Were you under any kind of doctors care on the date of your arrest? Yes Don't Know No

Are there any witnesses who were with you before or during your driving that can testify for you? Yes Don't Know No

Do you have any prior injuries, or present disabilities, that might have affected your driving or testing that night/day? Yes Don't Know No

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