Name

Email Address

Phone Number

Address

City

State

Zip

Work

Mobile

Fax/Other

Do you have a court date? Please provide details:

City and county of arrest:

Arresting officer's name and badge number, if known:

Blood-alcohol concentration (BAC) level at time of arrest, if known:

Type of test used to determine BAC, if a test was administered.

Were field sobriety tests given?
Yes  No 

If so, describe tests and results.

What was the specific drunk-driving offense for which you were arrested (include code section, if known)?

Have you been convicted of drunk driving before?
Yes  No 

If yes, please provide details:

Have you been convicted of other offenses?
Yes  No 

If yes, please provide details:

Are you on probation or parole?
Yes  No 

If yes, for what?

Do you have any other cases pending? If yes, please provide details:

Was anyone else arrested in the current incident?
Yes  No 

If yes, please provide the name(s) of all persons arrested:

What statements do you remember making to the police about the alleged drunk driving?

Describe the order of events leading up to the arrest.

Have you discussed the alleged drunk driving with anybody else?
Yes  No 

If yes, with whom and what did you say?

Were there any witnesses to the alleged drunk driving?
Yes  No 

If yes, provide names and contact information if known.

Did you post a bond? If yes, what was the amount of the bond?

Are there any special bond conditions? If yes, please describe the bond conditions.

Do you have any special concerns?

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