First
Name :
Last
Name:
Address:
City:
State:
Choose State
Georgia
South Carolina
Other
Zip:
Phone
#:
Okay
to call you at this number?
yes
no
Fax:
Okay
to fax you at this number?
yes
no
E-mail:
Okay
to e-mail you at this address?
yes
no
How
did you find this web site?
Choose One
Alta Vista
Yahoo
AOL
Lycos
HotBot
Web Crawler
Go!
Other
Please
specify how you found us, if not listed above:
Date
of Arrest:
Time
of Arrest:
Day
of the Week:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
State
Where Arrested:
City
Where Arrested:
County
Where Arrested:
Court
Date (leave blank in unsure):
Time
of Court:
Name
of Court:
State
Where Licensed:
Date
of Birth:
Is
this your first DUI in your lifetime - anywhere, anytime?
yes
no
If
you have had prior DUI's please list them below:
Month/Year - Court - Result (Guilty, Not Guilty,
Nolo)
Are
you currently on probation or parole?
yes
no
If
"yes", where?
Other
Tickets/Charges received with this DUI (check all
that apply):
Driving
Under Suspension
Possession
of Drugs
No
Seat Belt
Open
Container of Alcohol
Other
(Please specify below...)
Please
specify other charges not listed above
Why
were you stopped/arrested, according to officer?
Was
there an accident?
yes
no
Was
anyone injured? (check all that apply):
No
one was hurt/Not applicable
Myself
Passenger(s)
in my vehicle
Passenger(s)
in another vehicle
Pedestrian
Not
Sure
Were
you stopped at a road block?
yes
no
Were
you given a sobriety test?
yes
no
Don't recall
Refused
Which
field sobriety tests were you given? (Check all that
apply)
Walk-and-turn
(heal to toe)
One-leg
Stand
Follow-the
-Pen-With-Eyes (HGN)
ABC's
Touch
Your Nose
Other
(Please specify below...)
Please
specify other tests you took, that are not listed
above
Did
officer advise you that tests were 100% optional and
that no penalty would result from not doing them?
yes
no
Did
you take a breath test?
Yes
No,
I Refused
No,
Test Was Not Offered to Me
No,
I Was Given a Blood Test
Not
Sure
WARNING:
IF YOU REGISTERED A .15 OR MORE OR IF YOU WERE CHARGED
WITH REFUSING THE TEST YOU FACE AN AUTOMATIC 90 DAY SUSPENSION
OF YOUR LICENSE. TO TRY AND GET YOUR LICENSE BACK YOU HAVE 30 BUSINESS DAYS FROM THE
DATE OF YOUR ARREST TO FILE A "REQUEST FOR HEARING"
WITH THE DEPARTMENT OF PUBLIC SAFETY. CALL OUR OFFICE
IMMEDIATELY FOR ASSISTANCE!
If
you took a breath test please list your breath results
here:
Blood
test results:
Check here is test results are pending
Name
of testing officer:
Name
of arresting officer:
Name
of police department:
County
where stopped
Was
your car towed?
yes
no
Who
called the tow truck?
I Did
Officer Did
Not Sure
Who
posted bond?
I Did
Bonding Company
Family Member/Friend
Other
Was
there any witnesses with you who could testify for
you?
yes
no
At
any time during your arrest did you ever ask or inquire
about getting your own independent blood, breath,
or urine test?
yes
no
Did
you get an independent blood, breath or urine test?
yes
no
If
"yes", what was the result?
Check here if test results are pending
Did
you ever ask to call an attorney?
yes
no
If
"yes", when (give details)?
Additional
comments: