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Name


Email Address


Phone Number


Driver's license number


Date of Birth




Court where you are to appear


Date you are scheduled to appear


Is this your first DUI?
Yes
No


Are you currently on probation or parole?
Yes
No


Have you requested your DMV Hearing?
Yes
No




Date of Arrest


Time of Arrest


City Where Arrested


Which law enforcement agency arrested you? (Example: California Highway Patrol)


Did the officer observe you driving a vehicle?
Yes
No


Did you admit to driving the vehicle?
Yes
No


Was there an accident?
Yes
No


Were you stopped at a road block?
Yes
No


Were you under 21 years of age at the time of arrest?
Yes
No


Was there a child under 14 years of age in the vehicle at the time of arrest?
Yes
No


If you were on surface streets, were you speeding 20 MPH or more beyond the posted speed limit?
Yes
No


If you were on surface streets, were you speeding 30 MPH or more beyond the posted speed limit?
Yes
No


Did you tell the officer you had been drinking?
Yes
No


What time did you tell the officer that you had your last drink?


Did you perform any Field Sobriety Tests?
Yes
No


Did the officer ask you to blow into a handheld breath device at the scene?
Yes
No


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 you took a breath test, was the officer continuously observing you 15 minutes prior to the administration of that test?
Yes
No


If you took a chemical test (i.e., blood or breath), do you know the result?
Yes
No


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?
Yes
No


Did the officer advise you of your Miranda Rights?
Yes
No


Are you aware if you were videotaped at anytime during your arrest?
Yes
No


Additional Comments


 
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