First Name

Last Name

Address 1

Address 2

City

State

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Washington Wisconsin Wyoming

ZIP

Phone #

Email

How would you like me to reply?

 EMAIL        TELEPHONE

Date of Arrest

State Where Arrested

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Washington Wisconsin Wyoming

City Where Arrested

County Where Arrested

Court Date (leave blank if unsure)

Name of Court

Driver's License #

State Where Licensed

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Washington Wisconsin Wyoming

Date of Birth

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31       JANUARY FEBRUARY MARCH APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER       1902 1903 1904 1905 1906 1907 1908 1909 1910 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1999 2000

Is this your first DWI/DUI/BWI in your lifetime--anywhere, anytime?

Yes No

If you have had prior DWI/DUI/BWIs  please list them here:

Are you currently on probation or parole?

Yes No

If "yes", where?

If "yes", for what offense(s)?

Why were you stopped/arrested, according to the officer (check all that apply):

Why were you stopped/arrested, according to you and what are the facts of the case?

Was there an accident?

Yes No Not Sure

Was anyone injured? (Check all that apply):

Were you given field sobriety tests at the location where you were stopped?

Yes     No     Don't recall      I Refused

Which field sobriety tests were you given? (Check all that apply)

Please specify other tests you took, that are not listed above

Were you videotaped at any point during your arrest?

Yes No Not Sure

Did you take breath test?

What were the results of the breath test (if known)?

Did you take a Blood test?

Yes     No

Blood test results (if known)

Check here if test results are pending

Name of law enforcement agency