IF YOU ARE FACING A CHARGE FOR DUI/DWI/DRUNK DRIVING, YOU CAN RECEIVE A FREE EVALUATION OF YOUR CASE BY COMPLETING THE ABOVE CONFIDENTIAL QUESTIONNAIRE, OR BY SIMPLY CALLING US TOLL-FREE AT:
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Are you interested in fighting your case for the best result possible?
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| Date of Arrest: |
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| Time of Arrest: |
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| Town/Municipality Where Arrested Occurred: |
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| State of Arrest: |
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| Ask a Question: |
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| Day of Week: |
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| Court Date: |
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| Time of Court: |
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| Street or location where you were stopped: |
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| Was there a breath test taken on the scene? |
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Result: |
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| Was there a breath test at the police station? |
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Result: |
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| Was there a blood test taken? |
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Result: |
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| Is this your first arrest for DUI/DWI/Drunk Driving in your lifetime-anywhere? |
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| Please list all prior DUI/DWI/Drunk Driving Arrests (even if dismissed) below, including year, city/state, and outcome (if known): |
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| Are you currently on probation/parole for any DUI or criminal case? |
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If "yes", for what offense(s): |
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| Other tickets/Charges received with your present DUI Charge: |
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Improper Lane Usage
Speeding
Red Light/Stop Sign Violation
No Insurance
Accident
No Headlights
Equipment Violation
No Seat Belt
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| Why were you stopped according to the police officer? |
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| Was there an accident? |
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| Was anyone injured? (Check all that apply): |
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No one was hurt
Myself
Passenger in my vehicle
Passenger in another vehicle
Pedestrian
Not_Sure
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| Were you stopped at a roadblock? |
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| Were you given field sobriety tests at the scene, hospital or police station? |
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| Which tests were you given? (Check all that apply): |
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Portable Breath Test at scene
Eye Test (also known as Horizontal Gaze Nystagmus
Walk the Line
Finger to nose
Counting
Alphabet
Stand on one leg
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| Did any police tell you that the tests were optional (you could refuse)? |
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| Were you videotaped at the scene or police station? |
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| Do you want to challenge the possible suspension of your drivers license? |
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| Do you need driving privileges for (check all that apply): |
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Work
School
Medical care
Transporting your children
Personal errands
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| At any time did the police tell you that (check all that apply): |
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Your have the right to remain silent
You have the right to an attorney of your choosing
If you cannot afford an attorney, one will be appointed for you
Anything you say will be held against you in court
You can stop talking at any time
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| Did you ever tell the police that you wanted to speak to an attorney? |
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| Did you ever ask for an independent test of your own? |
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| Is it possible that there was drugs/medications in your system? |
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| Were you under any kind of doctors care on the date of your arrest? |
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| Are there any witnesses who were with you before or during your driving that can testify for you? |
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| Do you have any prior injuries, or present disabilities, that might have affected your driving or testing that night/day? |
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Additional Comments:
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IF YOU ARE FACING A CHARGE FOR DUI/DWI/DRUNK DRIVING, YOU CAN RECEIVE A FREE EVALUATION OF YOUR CASE BY COMPLETING THE ABOVE CONFIDENTIAL QUESTIONNAIRE, OR BY SIMPLY CALLING US TOLL-FREE AT:
1-800-DIAL-DUI
1-800-DIAL-DWI |
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| 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. |
