Contact Information

This is a secure form. All information herein will be kept confidential.

Name First Last
Email
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Main Phone - (###) - ### ####
Work Phone - (###) - ### ####
Other Phone - (###) - ### ####
Date of Arrest / MM / DD YYYY
Referred by First Last
Did you refuse to take a BAC test? Yes No
Did you try to take the test but they said you refused? Yes No
Did you score at or above a 0.08? Yes No
Were you under 21 and scored at or above a 0.02? Yes No
Did you have a CDL, were in your work vehicle and scored at or above a 0.04? Yes No
Are you not sure what you blood alcohol level was? Yes No
Did you get a yellow piece of paper "8 1/2 inches by 11 inches" entitled "Sworn Report of the Arresting Officer"? Yes No
If you answered 'Yes' to any of the above questions, you must file for a special hearing within 10 days from the date of your arrest. Failure to do so will result in a 1-year suspension of your license.
You can now submit the above portion of the form for contact purposes or fill out the rest of the form and submit for your free evaluation.