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First Name*

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Middle Name

Last Name*

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Company Name

Email Address*

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Home Phone

Cell Phone*

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Work Phone*

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Are you interested in fighting your case for the best result possible?

Yes

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

If yes what was the result

Was there a breath test at the police station

Yes

If yes what was the result

Was there a blood test taken

Yes

If yes what was the result

Is this your first arrest for DUI/DWI/Drunk Driving in your lifetime-anywhere, even if dismissed?

Yes

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

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

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

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

Yes

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

Were you videotaped at the scene or police station?

Yes

Do you want to challenge the possible suspension of your drivers license?

Yes

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

Did you ever ask for an independent test of your own?

Yes

Is it possible that there was drugs/medications in your system?

Yes

Were you under any kind of doctors care on the date of your arrest?

Yes

Are there any witnesses who were with you before or during your driving that can testify for you?

Yes

Do you have any prior injuries, or present disabilities, that might have affected your driving or testing that night/day?

Yes

Additional Comments

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