Your Name:
Email:
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
Marital Status:
Number of Children:
Home Phone:
Work Phone:
Cell Phone / Beeper:
SSN#:
Drivers License:
State:
Number:
Date of Birth:
Age:
Height:
Weight:
Gender:
Highschool:
College:
Post Grad.:
Were you in the armed forces?
no
yes
If yes, what branch:
Employer:
Job Title / Duties
Earnings:
(optional)
Miles traveled per year:
Does your job depend on having a driver's license?:
no
yes
If yes, how many miles do you travel per year for your employer?
Did the arresting officer read you your Miranda rights?
no
yes
If yes, when?
Were you involved in an accident?
no
yes
If yes, give details:
Were you asked if you had been drinking?
no
yes
If yes, what was your answer?
Did you tell the officer how many drinks you had?:
no
yes
Where had you been drinking?
What were you drinking and how many drinks did you have?
Did you have any passengers in the car with you at the time you were arrested?
no
yes
If so, please give the number of passengers and the names of each passenger:
Do you feel that the alcoholic beverages you had consumed had any effect on your ability to drive your automobile?
no
yes
If yes, how?
Were you taking any medication at the time of the accident?
no
yes
If so, please indicate the name of the medication and dosage taken at the time of the arrest:
Do you have any physical disabilities causing you to have poor balance or to limp?
no
yes
If so, please indicate:
If yes, what type of medication do you take for treatment of this disease:
Do you have any dental work, such as unfinished root canals, which could trap mouth alcohol?
no
yes
If yes, please indicate:
Do you have heart disease or high blood pressure?
no
yes
If yes, please indicate what kind of medication you take, if any:
Do you wear glasses or contact lenses?
no
yes
If so, please state the type of corrective lense that you wear:
At the time of the arrest, did you request to talk to an attorney?
no
yes
If so, please describe:
Do you have any prior DUI convictions or arrests?
no
yes
If yes, please indicate the dates and locations of prior DUI arrests or convictions:
Do you feel that you have a problem with alcohol or drugs?
no
yes
If yes, please state the nature of your problem:
Do you wish to receive counseling for alcohol or drug use?
no
yes
If yes, please advise what type of counseling you would like to have:
Do you have a criminal record other than prior DUI convictions or arrests?
no
yes
If yes, please give the nature of the charge and the dates of the offenses:
Do you authorize us to discuss your case with any family member or friend?
no
yes
If so, please list all person(s) with a complete address, phone and relationship:
