First Name

Last Name

Address

City

State

ZIP

Phone #

Okay to call this number?

 Yes  No

Alternate Phone #

Okay to call this number?

 Yes  No

Alternate number is a

FAX

Okay to fax this number?

 Yes  No

Email (required)

Okay to email?

 Yes  No

How did you find our web site?

Please specify how you found us, if not listed above

Are you mainly interested in fighting your DUI, or do you want to plead no contest or guilty?

Date of Arrest

Time of Arrest

Day of the Week

State Where Arrested

City Where Arrested

County Where Arrested

Court Date

Time of Court

Name of Court

Driver's License #

State Where Licensed

Date of Birth

Is this your first DUI in your life?

 Yes  No

Are you currently on probation or parole?

 Yes  No

If "yes", where?

Other Tickets/Charges received with this DUI (check all that apply):

 Failure to Maintain Lane
 Speeding
 Illegal U-Turn
 Running Red Light
 Defective Equipment
 No Proof of Insurance
 Failure to Yield
 Other (Please specify below...)

Was there an accident?

 Yes  No  Not Sure

Was anyone injured? (check all that apply):

 No one was hurt/Not applicable
 Myself
 Passenger(s) in my vehicle
 Passenger(s) in another vehicle
 Pedestrian
 Not Sure

Were you stopped at a roadblock?

 Yes  No

Were you given field sobriety tests at the location where you were stopped?

 Yes   No  Don't recall  Refused

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

 Handheld Breath Test
 Walk-and-turn 9 steps heel to toe
 One-Leg Stand
 Follow-the-Pen-With-Eyes
 Say the Alphabet
 Touch Your Nose
 Other (Please specify below...)

Please specify other tests you took, that are not listed above

Did officer advise you that tests were 100% optional and that no penalty would result from not doing them?

 Yes  No

Did you take chemical test?

 Breath Test
 Blood Test
 Urine Test
 No, I Refused
 No, Test Was Not Offered to Me
 Not Sure

Chemical test result

Check here if test results are pending

Name of testing officer

Name of arresting officer

Name of police department

Street/location of stop

County where stopped

Was your car towed?

 Yes  No

Who called the tow truck?

 I Did  Officer Did  Not Sure

Who posted bond?

 I Did  Bonding Company
 Family Member/Friend  Other

Were there any witnesses with you who could testify for you?

 Yes  No

At any time during your arrest did you ever ask for or inquire about getting your own independent blood, breath or urine test?

 Yes  No

Did you get an independent blood, breath or urine test?

 Yes  No

If "yes", what was the result?

Check here if test results are pending

Did you ever ask to call an attorney?

 Yes  No

If "yes", when (give details)