| 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 Highway Patrol, City Police Department)
|
|
| Is this your first DUI?:
|
|
| If you have had prior DUI's, please list dates and court and results:
|
|
| Are you currently on probation or parole?
|
|
| If yes, for what offense and in what State, City County?
|
|
| Have you requested your DMV Hearing?
|
|
| Did the officer observe you driving a vehicle?
|
|
| Did you admit to driving the vehicle?
|
|
| Was there an accident?
|
|
| If so, were there any injuries as a result of that accident?
|
|
| Were you stopped at a road block?
|
|
| Were you under 21 years of age at the time of the arrest?
|
|
| Was there a child under 14 years of age in the vehicle at the time of arrest?
|
|
| If you were on surface streets, were you speeding 20 MPH or more beyond the posted speed limit?
|
|
| If you were on the freeway, were you speeding 30 MPH or more beyond the posted speed limit?
|
|
| Did you tell the officer you had been drinking?
|
|
| 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?
|
|
| Did the officer ask you to blow into a handheld breath device at the scene?
|
|
| If so, did the officer advise you that you had a right to refuse that on-scene breath test?
|
|
| 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?
|
|
| If so, which test did you take?
|
|
| If you took a breath test, was the officer continuously observing you 15 minutes prior to the administration of that test?
|
|
| If you took a chemical test (i.e., blood or breath), do you know the result?
|
|
| 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?
|
|
| Did the officer advise you of your Miranda Rights?
|
|
| Are you aware if you were videotaped at anytime during your arrest?
|
|
| Additional Comments
|
|
| |
|
