Name (*)

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Email Address (*)

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Phone Number

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Cellular or Pager

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Address

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City

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State

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Zip

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Booking #

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Driver's License #

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Court Date

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Time

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Court Name

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Division/Room

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Arresting Officer's Name and Badge

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City of Arrest

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What specific drug offense were you arrested for (include Code/statute section, if known)?

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Have you been convicted of a drug violation before?
yes   no
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If yes, when?

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Describe the circumstances of the past drug violation and your sentence, if any

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Have you been convicted of other offenses?
yes   no
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If yes, what and when?

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Have you been through drug treatment in the past?
yes   no
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Are you on probation or parole?
yes   no
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For what?

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Do you have any other cases pending?
yes   no
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Was anyone else arrested?
yes   no
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If so, name(s) of all persons arrested

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What statements do you remember making to the police about the alleged drug offense?

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Describe the order of events leading up to the arrest

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Have you discussed the alleged drug offense with anybody else?
yes   no
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If so, whom did you discuss it with and what did you tell them?

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Were there any witnesses to the alleged offense?
yes   no
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If yes, provide names and contact information if known

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What is the amount of the bond you posted?

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Are there any special bond conditions?

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Were you referred by somebody else?
yes   no
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Who?

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Special concerns

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