DUI/DWAI INTAKE FORM
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1. First name:

2. Last name:

3. Street Address:

4. City:

5. State:

6. Zip Code:

7. Work Phone:

8. Home Phone:

9. Cell Phone:

10. Fax Number:

11. Email Address:

12. How did you hear about us?
13. Have you requestesd a DMV hearing?

Yes No

14. If so, when?

15. Date of Arrest:

16. Is your license particularly important for work?

Yes No

17. What type of work?

18. When is your court date?

19. Your age?

20. Were there any other charges with this arrest?

21. Do you have any prior DUIs?

Yes No

22. Have you consulted with another attorney?

Yes No

23. Who was the other attorney (if applicable)?

24. Did you pay attorney fees (if applicable)?

Yes No

25. Was there an accident involved?

Yes No

26. Were there any injuries? Please explain.

Breath Blood

27. Were you stopped at a roadblock/checkpoint?

Yes No

28. FST Given:

29. Did you refuse a blood or breath test?

30. If not, what type of test did you take?

31. What was your BAC level?

Yes No

32. Name of arresting officer?

33. Police Department?