Personal Information
First Name

Last Name
Home Phone

Work Phone

Other Phone
Email Address

How did you find us?

How did you find us (other)?
What's the Best Time to Contact You: am pm
Where Would You Like to be Contacted: Home Work Other
Case Information
Date of Arrest
Upcoming Court Dates
  
Arresting Officer Judge's Name  
Court your case is in Court Time  

Why were you stopped by the police? (Check all that apply)

Speeding Accident Ran a red light Ran a stop sign
Improper Lane Change Weaving Roadblock Other
Did you submit to a breath, blood or urine test? Yes No Don't know

What were the results of the breath test (if you took one)? First breath sample Second breath sample

Did the officer read you the implied consent warnings (these warning are usually read from a card, telling you that if you don't take the breath, blood or urine test, that you will lose your license)?
Yes No Don't know
Did you take any field sobriety tests? Yes No Don't know

If yes, which tests? (check all that apply)

Recite the ABCs Follow a finger or pen with your eyes
Walk on a line, turn, and walk back Stand on one leg and count
Other (please specify):
Have you been arrested and convicted of DUI within the last five years? Yes No
Have you been arrested and convicted of DUI anytime in your life? Yes No
Have you ever been arrested [other than for moving violations (traffic tickets)] Yes No
Additional Comments: