Free Evaluation Section

Driver's License Number:
State
Date of Birth / MM / DD YYYY
Full Name of Court
How many DUIs have you had:
Month and year of prior:
Month and year of prior:
Month and year of prior:
Tickets and other citations received with this DUI:
Arresting officer: First Last
Type of officer:
Was the officer task force: Yes No
Accident: Yes No
Roadblock: Yes No
Open container: Yes No
Did you take the breath test: Yes No
Reading
Reason for refusing
Did you take the blood test? Yes No
Reading
Did you take the urine test? Yes No
Reading
Did you get an independent blood or urine test? Yes No
Hospital
Street where stopped:
County:
Why stopped?
Name of witnesses: First Last
Name of witnesses: First Last
Name of witnesses: First Last
Bondsman: First Last