Personal Information

Full Name:
Phone:
Email Address:
Driver's license number:
Date of Birth:

Incident Information

Date of Arrest:
Time of Arrest:
Court where you are to appear?
Date you are scheduled to appear?:
City Where Arrested:
Which law enforcement agency arrested you? (Example: California Highway Patrol, City Police Department)
Is this your first DUI?:
If you have had prior DUI's, please list dates and court and results:
Are you currently on probation or parole?
If yes, for what offense and in what State, City County?
Have you requested your DMV Hearing?
Did the officer observe you driving a vehicle?
Did you admit to driving the vehicle?
Was there an accident?
If so, were there any injuries as a result of that accident?
Were you stopped at a road block?
Were you under 21 years of age at the time of the arrest?
Was there a child under 14 years of age in the vehicle at the time of arrest?
If you were on surface streets, were you speeding 20 MPH or more beyond the posted speed limit?
If you were on the freeway, were you speeding 30 MPH or more beyond the posted speed limit?
Did you tell the officer you had been drinking?
If so, how much did you tell the officer you had been drinking?
What time did you tell the officer that you had your last drink?
Did you perform any Field Sobriety Tests?
Did the officer ask you to blow into a handheld breath device at the scene?
If so, did the officer advise you that you had a right to refuse that on-scene breath test?
How many times did you blow into the breath device?
At your arrest, were you advised that you had a choice between a blood or breath test?
If so, which test did you take?
If you took a breath test, was the officer continuously observing you 15 minutes prior to the administration of that test?
If you took a chemical test (i.e., blood or breath), do you know the result?
If so, what was the result? (Example: .08, .12, .20)
If you took a breath test at the station, how many times did you blow into the machine?
Were there any witnesses to your driving and/or arrest?
Did the officer advise you of your Miranda Rights?
Are you aware if you were videotaped at anytime during your arrest?
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Personal Information

Incident Information