Personal Information: Name:*
Address: City: State: ZIP:
Home Phone: Work Phone:
Other Phone: Email:
Age: Date of Birth:
Place of Birth:
U.S. Citizen Yes No
Military Yes No
Marital Status: Children Yes No
If yes, how many?
Do you have a valid driver's license? Yes No
Was it valid at the time of your arrest? Yes No
Do you have a commercial license? Yes No
Do you require a license for work purposes? Yes No Prior Arrests And/Or Convictions:
Prior Arrests And/Or Convictions: Is this your first DUI arrest? Yes No
Are you currently on probation? Yes No
If yes, explain: Current DUI:
Current DUI: What was the date of your DUI arrest?
What was the time of your DUI arrest?
Where was your automobile pulled over when you were detained?
What traffic citations were issued with your arrest?
Driving While License Suspended
License Not In Possession
Failure To Maintain A Single Lane
Disobeying A Traffic Control Device Such As A Stop Sign Or A Red Light
No Proof Of Insurance
Burned Out Tail Lamp
Failure To Conform To Unsafe Conditions
What did the officer say when you were pulled over?
Why were you detained?
If there was an accident, was anyone injured, including yourself, or passengers in your vehicle, or passengers in any other vehicle, and/or any pedestrians?
Were you stopped by a roadblock? Yes No
If so, were you pulled over while attempting to turn around and avoid the roadblock? Yes No
Did you perform field sobriety tests on the night of your arrest? Yes No
If so, were these exercises done at the scene where you were pulled over or at the blood alcohol testing facility?
Did you take a breath test? Yes No
Did any officer inform you of the consequences for not taking the breath test? Yes No
Did you provide a urine sample? Yes No
Did you provide a blood sample for testing? Yes No
Did you request an independent blood test? Yes No
If so, were you permitted to provide a blood sample for independent testing? Yes No
Were you informed of the results of any breath, blood or urine tests? Yes No
If so, what were those results?
What was the name of the officer who arrested you?
What were the names of any of the officers at the location of your arrest?
Are there any witnesses that were with you in the hours preceding your arrest? Yes No
Can they truthfully testify to how little, if anything, you had to drink prior to your arrest? Yes No
If so, please provide all names and contact information including what each witness may testify to if called to do so? Physical Condition At Time Of Arrest:
Physical Condition At Time Of Arrest:
Had you eaten prior to your arrest? Yes No
If so, at what time? What did you eat? Did you have anything to drink prior to your arrest? Yes No
If so, what time did you drink alcohol? What did you have to drink? How much did you have to drink?
Medical Condition At Time Of Arrest:
Do you have a physical disability? Yes No
If so, please explain disability:
At the time of your arrest, were you under the influence of any medications (including over the counter drugs)? Yes No
If so, what medications? Do you have any form of speech impediment? Yes No
Describe: Were you suffering from an upset stomach at the time of your arrest? Yes No
Do you wear glasses or contact lenses? Yes No
How many hours prior to your arrest had you gotten any meaninful sleep?
Please explain any special circumstances that may have lead to your being fatigued on the night of your arrest:
Condition Of Automobile At The Time Of Arrest:
What was the make, model and color of the automobile you were driving at the time of your arrest?
Were there any mechanical problems with the automobile that you were driving on the night of your arrest, including, but not limited to improper alignment, improper inflation of tires, brake problems, head lamp or tail lamp malfunctioning, or other:
When was the last time this automobile had been serviced? What was the location and contact information of the mechanic who serviced this automobile?
What Were The Weather And Road Conditions At The Time Of Arrest: Was it windy at the time of your arrest? Yes No
Moderate, medium or heavy? Was it raining at the time of your arrest? Yes No Moderate, medium or heavy?
How long had it been raining prior to your being pulled over and/or detained?
Please Indicate If There Is Anything About Your Dui Arrest That Has Not Been Covered In The Above Dui Questionnaire: Additional Information:
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