Name: Drivers License #:

Aliases, if any (e.g. Maiden, Prior marriage, etc.):

Weight: Height: Date of Birth:

Home Address:

Work Address:

Home Phone: Work or Cell Phone:

E-mail Address:

How would you like to be contacted?

Do you require a driver’s license for your job? Yes No

Are you a commercial driver? Yes No

How Did You Find Out About Our Services? (please check one)

Letter: Internet: Recommendation: Other:

Do you want legal representation in (please check one)?

Both Criminal and DMV action Criminal action only or DMV action only

Arrest Information:

What date did you get arrested?

Which agency arrested you:

What time were you pulled over?

Were you driving at that time? Yes No

Was an accident involved? Yes No

If so, were there any injuries? Yes No

Why did the police officer pull you over or investigate you?

What were you doing immediately before you were pulled over?

Had you been drinking prior to being stopped? Yes No

If so, what had you been drinking?

Describe your drinking that day, or the 12 hours before driving, include times (to the best of your knowledge)?

Had you taken any prescription medication or other drugs prior to being stopped? Yes No

Did you tell the officer you had been drinking or had taken any prescription medication or other drugs and if so, what did you tell the officer?

Did the officer ask you to perform any Field Sobriety Tests? Yes No

What Field Sobriety Tests did you perform?

a) Hand Pat
b) Recite/Write Alphabet?
c) Stand on One Leg
d) Tilt head back and quietly estimate 30 seconds?
e) Finger Count
f) Did the officer check your eye movements?
g) Walk in a straight line
h) Non-evidentiary breath test
(aka: preliminary alcohol screening device)
i) Other:

How do you think you did on the FST’s?

Do you have any physical disabilities that interfered with your performance on the Field Sobriety Tests?

Did the officer say anything to you?

Anything important that you noticed while taking the tests or conditions?

Do you have any physical conditions? (asthma, stomach illnesses, injuries (knees, back, eyes, etc.), medications, etc.)

Which chemical test did you take?

Blood Breath Urine Refusal

What were the results of the test?

What time did you take the test?

Were you offered a blood test at any time? Yes No

How long were you in jail?

Have you ever been charged or convicted of either a DUI offense or reckless driving? Yes No

If yes, how many years ago?

Were You represented by an attorney? Yes No

What was/were the outcome/s of these prior cases?

Anything else that you feel I should know about your case?

Hearing Information:

What day is your arraignment scheduled? Time?

What court?

Department?

Have you scheduled a hearing with the Department of Motor Vehicles? Yes No

Please be advised that you have 10 days after your arrest in order to request a DMV hearing or you may have waived your right to a hearing. Please advise me if you need to request a DMV hearing.

Has a DMV hearing already been set? Yes No

If yes, when?

Telephone hearing? In Person? Location of Hearing?