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Please fill out the form so we can better help you.

First Name*

Middle Name

Last Name*

Company Name

Email Address*

Home Phone

Cell Phone*

Work Phone*

Are you interested in fighting your case for the best result possible?
Yes
No

Date of Arrest

Time of Arrest

Town/Municipality Where Arrested Occurred

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
No

If yes what was the result

Was there a breath test at the police station
Yes
No

If yes what was the result

Was there a blood test taken
Yes
No

If yes what was the result

Is this your first arrest for DUI/DWI/Drunk Driving in your lifetime-anywhere, even if dismissed?
Yes
No

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

Are you currently on probation/parole for any DUI or criminal case
Yes
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

Any other tickets please list them here

Why were you stopped according to the police officer

Was there an accident
Yes
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
No

Were you given field sobriety tests at the scene, hospital or police station?
Yes
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

Any other tests given please list here

Did any police tell you that the tests were optional (you could refuse)?
Yes
No

Were you videotaped at the scene or police station?
Yes
No

Do you want to challenge the possible suspension of your drivers license?
Yes
No

Do you need driving privileges for (check all that apply):
Work
School
Medical care
Transporting your children
Personal errands

Did you ever tell the police that you wanted to speak to an attorney?
Yes
No

Did you ever ask for an independent test of your own?
Yes
No

Is it possible that there was drugs/medications in your system?
Yes
No

Were you under any kind of doctors care on the date of your arrest?
Yes
No

Are there any witnesses who were with you before or during your driving that can testify for you?
Yes
No

Do you have any prior injuries, or present disabilities, that might have affected your driving or testing that night/day?
Yes
No

Additional Comments

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