Name (*)

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Email Address (*)

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Phone Number

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Address

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City

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State

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Zip

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Work

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Mobile

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Fax/Other

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Do you have a court date? Please provide details

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City and county of arrest

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Arresting officer's name and badge number, if known

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Blood-alcohol concentration (BAC) level at time of arrest, if known

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Type of test used to determine BAC, if a test was administered.

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Were field sobriety tests given?
yes   no
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If so, describe tests and results.

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What was the specific drunk-driving offense for which you were arrested (include code section, if known)?

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Have you been convicted of drunk driving before?
yes   no
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If yes, please provide details:

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Have you been convicted of other offenses?
yes   no
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If yes, please provide details

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Are you on probation or parole?
yes    no
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If yes, for what?

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Do you have any other cases pending? If yes, please provide details

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Was anyone else arrested in the current incident?
yes   no
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If yes, please provide the name(s) of all persons arrested

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What statements do you remember making to the police about the alleged drunk driving?

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Describe the order of events leading up to the arrest.

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Have you discussed the alleged drunk driving with anybody else?
yes    no
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If yes, with whom and what did you say?

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

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Did you post a bond? If yes, what was the amount of the bond?

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Are there any special bond conditions? If yes, please describe the bond conditions.

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Do you have any special concerns?

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