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