Full Name:
Phone:
Email Address:
Driver's license number:
Date of Birth:
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 Hwy Patrol)
Is this your first DUI?:
--
Yes
No
If you have had prior DUI's, please list dates and court and results:
Are you currently on probation or parole?
--
Yes
No
If yes, for what offense and in what State, City County?
Did the officer observe you driving a vehicle?
--
Yes
No
Did you admit to driving the vehicle?
--
Yes
No
Was there an accident?
--
Yes
No
If so, were there any injuries as a result of that accident?
--
Yes
No
Were you stopped at a road block?
--
Yes
No
Were you under 21 years of age at the time of the arrest?
--
Yes
No
Was there a child under 14 years of age in the vehicle at the time of arrest?
--
Yes
No
If you were on surface streets, were you speeding 20 MPH or more beyond the posted speed limit?
--
Yes
No
If you were on the freeway, were you speeding 30 MPH or more beyond the posted speed limit?
--
Yes
No
Did you tell the officer you had been drinking?
--
Yes
No
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?
--
Yes
No
Did the officer ask you to blow into a handheld breath device at the scene?
--
Yes
No
If so, did the officer advise you that you had a right to refuse that on-scene breath test?
--
Yes
No
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?
--
Yes
No
If so, which test did you take?
--
Blood
Breath
If you took a breath test, was the officer continuously observing you 20 minutes prior to the administration of that test?
--
Yes
No
If you took a chemical test (i.e., blood or breath), do you know the result?
--
Yes
No
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?
--
Yes
No
Did the officer advise you of your Miranda Rights?
--
Yes
No
Are you aware if you were videotaped at anytime during your arrest?
--
Yes
No
Additional Comments
