Full Name:

Day Phone #:

Evening Phone #:

Email Address:

Street Address

City, State & Zip Code:

Driver's License #:

Driver's License State:

Occupation:

Are you currently on probation or parole?

Yes No

If yes, please explain the circumstances of your probation or parole (be specific):

Is this your first DUI?

Yes No

If not, please explain the circumstances of your last one (be specific, providing dates, locations, and outcomes):

Date of Arrest:

City, County, and State of Arrest:

Date are you to appear in Court:

Arresting officer's affiliation:

Type of test taken:

Officer's Name:

Officer's Badge Number:

Ticket Number:

What reason did the officer give for stopping you? (be as specific as possible):

What other types of sobriety tests did the officer have you perform? (be as specific as possible):

Breath Test Blood Test A test was not offered to me I refused to take a test I don't know

Was there an accident involved?

Yes No

Was anyone else in the car?

Yes No

If yes, were any of the people in the car under 18?

Yes No p

Enter any other pertinent information here: