Your Name:

Your Address:

Your Email:

Your Telephone numbers (Home/Business/Mobile/Pager):

Your Age:

Service in armed forces?
YesNo

Where do you work and what do you do there?

What is your marital status?:

The Arrest

Date of Arrest:
JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 12345678910111213141516171819202122232425262728293031 200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980

Time of Arrest
AMPM

Place of arrest and reason for initial stop:

List the name of all of the officers involved (arresting officer, officer conducting field sobriety test, officer conducting horizontal gaze nystagmus test, and the officer conducting the breath test)

If you took the online breath test what were your results

You can take it now by clicking here. Just close the windows afterwards to return here.

What were you doing in the hours before your arrest? Please including anything you said to the police officer(s) and what the police officer(s) said to you. Please supply as much detail as possible.

Were Miranda warnings given to you?

Did you speak to anyone other than the police? If so, what did you say?

Were you given any field sobriety, or coordination tests (walk-the-line, heel-to-toe, finger-to-nose, stand-on-one leg, recitation of the alphabet, etc.)? If so, what tests, when and where were they given? How do you feel you did with respect to each test? If you refused to take any of these tests, were you told what would happen?

At the time of the arrest, did you take a Breath Test? If so, what was the result?

How much sleep had you had 24 hours prior to the tests?

Were you or your vehicle searched? Were you asked for permission to search? What was found?

Did you consider yourself to be impaired?

Consumption prior to arrest:

Time of last drink

I had
US beer(s)Light beer(s)Reduced alcohol beer(s)Pint(s) of beerMalt liquor(s)Glass(es) of table wineGlass(es) of ChampagneGlass(es) of Fortified/Dessert wineBloody Mary(s)Gin and Tonic(s)Highball(s)Irish Coffee(s)On the RocksPina Colada(s)Screwdriver(s)Tom CollinsWhiskey Sour(s)Margarita(s)Airline miniature(s)Gimlet(s)Old-fashioned(s)Mint Julep(s)Black Russian(s)Dry Martini(s)Manhattan(s)Rob Roy(s)Double(s) on the Rocks Frozen Daiquiri(s)
over a period of hour(s).

What had you eaten?

Names, addresses and phone numbers of all persons who were with you while you were drinking or when you were stopped. Would they be willing to testify on your behalf? What do you believe they would say?

Did you drink any alcohol after this incident began?

Vehicle Information

What are the make, year, and model?

Prior DUIs

Do you have any prior DUIs?

Are you on probation? If so, what for, what are the terms of probation?

Other Information

Is there any other information that you feel is important?