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Were You Charged With a DUI or DWI?
Complete This Brief Intake Form
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All Information Will Remain Confidential
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SSN
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Drivers License #
Drivers License Issue Date
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Court Date
What Were You Charged With?
Have You Ever Received a DWI/DUI/Other Alcohol Related Driving Offense Before?
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If Yes, What Was Your Date of Conviction
In What State?
Do You Have CDL?
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Is Your Driver's License Currently Active?
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If Not, Is Your License Revoked or Suspended For A DWI or Other Alcohol Related Offense?
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Have You Had Any Traffic Violations or Speeding Tickets Within The Last 5 Years?
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If Known, What Was Your Alleged BAC?
Did You Submit A Breath Test (Blow Into A Machine)?
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No
Did You Refuse A Breath Test?
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Did You Ask For A Witness During Your Breath Test?
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No
If Applicable, Did The Witness Show Up?
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Was Your BAC Obtained By Taking A Sample Of Your Blood?
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Did A Police Officer Pull You Over?
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No
If So, Why Did The Police Officer Pull You Over?
If You Were Not Pulled Over, How Did The Police Come In Contact With You?
Did You Have People In The Car With You?
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Can Those People Testify On Your Behalf?
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Were You Involved In An Accident?
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If So, Was Anyone Injured In the Accident?
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No
If There Were Injuries, How Severe Were They?
Were There Any Minors (under 18) In Your Vehicle?
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No
Who Was The Charging Officer and Charging Agency (On Your Citation)
Did You Submit To Sobriety Tests Before You Were Arrested (I.E. Walk And Turn, One Leg Stand, Reciting The Alphabet, etc)?
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No
How Long Were You In Jail/Custody Before You Were Released?
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