NOTE: * indicates a required
field.
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Personal Information |
Name* |
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Date of Birth (mm/dd/yyyy) |
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Address |
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City, state, zip |
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Country |
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Phone*:
(At least one phone number is required.
Use the format 555-555-5555.)
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Fax |
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E-mail |
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Case Information |
Describe what happened.* Please include the date, time and place. |
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Was there a car accident with the DUI?
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Yes
No
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Do you have a court date?
Where is it and when?
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Did you call the DMV for a hearing?
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Yes
No
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Briefly explain any prior criminal record,
arrests, convictions, dates and charges. |
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Which police department arrived?
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Breath results
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At the scene
%BAC
At the station
%BAC
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Do you have any photos, reports, bills, estimates or any other documents? |
Yes
No
If yes, please describe what you have.
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Were you arrested?
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Yes
No
Please provide your booking number and name of the jail.
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Were any recorded or written statements given or signed during this incident? |
Yes
No
If yes, when and to whom?
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Were you given a ticket?
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Yes
No
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Was your drivers license valid during this incident? |
Yes
No
If not, when and why was it suspended?
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Has your drivers license ever been suspended before this incident? |
Yes
No
When and why was it suspended?
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Was your car searched?
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Yes
No
What was found?
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Other Details |
Are you completing this form
on behalf of someone else? |
Yes
No
If yes, please provide your contact information.
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How would you pay for
fees in this matter? |
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Please tell us how you
found our web site. |
West / FindLaw Legal
Directory (Lawoffice.com)
Martindale-Hubble Legal
Directory (Lawyers.com)
Verizon Superpages
Directory (SuperPages.com)
SBC Smartpages
Directory (Smartpages.com)
Google Search Engine
(Google.com)
AOL Search (AOL.com)
Yahoo! Search (Yahoo.com)
Other (please
indicate):
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