NOTE: An Asterisk (*) Indicates REQUIRED Information.

*Name: Date:
Your class of license: State where licensed:
Do you have a CDL license: Select Yes No If yes, class of license: why:
Did the officer confiscate your license: Select Yes No
Prior Criminal Record:
Any prior DUIs: Select Yes No If yes, date: Actual charge:
Location (County and State):
Disposition:
Arrest for other charges:
Prior Driving Record:
Have you ever had a withheld judgment? Select Yes No
What did you do during the ten (10) hours prior to the time you started drinking:
Date of this incident:
When did you eat last prior to being stopped?
Are you on a special diet? Select Yes No If yes, what?
Time started drinking:
Location drinking:
What were you drinking?
Time of last drink?
Total drinks:
Time of stop:
What law enforcement agency stopped you: Select State Police County Sheriff City Police

STOP BY OFFICER

Reason officer gave for stop?
Do you agree with that reason? Select Yes No
Was there any law violation justifying the stop? Select Yes No If yes, what?
In general terms, what happened after the officer stopped you?

Please indicate which of the following field sobriety tests were given and the order given by putting 1, 2, 3 in front of the appropriate test (and describe briefly how you did on the test and any adverse conditions; e.g. flashing lights, slope of ground, weather conditions, passing traffic, interruptions and the like)

Horizontal gaze nystagmus test (eye test)
How did you perform on test?
Adverse conditions:

Walk and Turn
How did you perform on test?
Adverse conditions:

One leg stand
How did you perform on test?
Adverse conditions:

Alphabet
How did you perform on test?
Adverse conditions:

Counting test
How did you perform on test?
Adverse conditions:

Other tests:
How did you perform on test?
Adverse conditions:

AT ANNEX

What kind of test were you given? Select Breath Blood Urine None
If no test was given, please state the reason you refused:

IF BREATH TEST:
a. How long were you observed prior to the test?
b. Did you have anything in your mouth (gum, chew, tongue ring)?
c. Did the officer check your mouth? Select Yes No
d. Do you remembering burping or belching before test? Select Yes No
e. Anything unusual happen with respect to the breath test?
f. Did the officer have any trouble programming it? Select Yes No . If so, please describe:
g. How many officers were in the room when the breath test was administered?
h. Did the officer ask you if you had any exposure to paints, glues, solvents or consumed any alcohol of solvent other than ethyl alcohol? Select Yes No

If yes, what did you tell the officer?
Was that answer correct? Select Yes No
If no, how would you have answered the question?

GENERAL HISTORY

Any physical defects or limitations that affect their balance, speech or dexterity? Select Yes No If so, what?
On date of incident? What it was?
Under doctor's care? How it affects you.
Do you have a hiatal hernia? Select Yes No Do you have acid reflux? Select Yes No

Were you taking any drugs or medications? Select Yes No If so, what?

Are there any warnings with respect to the use of medication with alcohol?

Any diabetes in family? Select Yes No If so, who? Have you ever been checked for diabetes? Select Yes No

Do you have false teeth or plates? Select Yes No

Do you believe that you were under the influence? Select Yes No

Do you believe that you were drunk? Select Yes No

Do you believe that your operation of the vehicle was affected by the alcohol that you consumed? Select Yes No

What would you like to see happen with respect to the pending charge? (Dismissed, reduced, etc.)

We need the people, who would have seen you drinking or who had contact with you at any time before or within a reasonable period of time after the arrest to establish things as it relates to your drinking and sobriety? Please list the name(s), address(es) and telephone number(s) of all witnesses.
1.
2.
3.
4.

Did you spend any time in jail? Select Yes No . If yes, how much time?

Note: The use of the Internet for communications with the firm will not establish an attorney-client relationship and messages containing confidential or time-sensitive information should not be sent.