DUI / DWI Client Questionnaire

If you are facing a drunk driving charge, you can receive a FREE consultation for your case. Just complete the form below and submit it to us, or you can call our NATIONWIDE TOLL-FREE NUMBER at 1-888-DUI-CHARGE (1-888-384-2427).

First Name
Last Name
Address 1
Address 2
City
State
ZIP
Phone #
Okay to call you at this number?	Yes No
Alternate Phone#
Okay to call you at this number?	Yes No
Alternate number is a
FAX
Okay to fax you at this number?	Yes No
Email
Okay to email you at this address?	Yes No
How did you find this web site?
Please specify how you found us, if not listed above
Are you mainly interested in fighting your DUI / DWI, or do you want to plead nolo or guilty?
Date of Arrest
Time of Arrest
Day of the Week
State Where Arrested
City Where Arrested
County Where Arrested
Court Date (leave blank if unsure)
Time of Court
Name of Court
Drivers License #
State Where Licensed
Date of Birth
Is this your first DUI / DWI in your lifetime--anywhere, anytime?	Yes No
If you have had prior DUIs / DWIs please list them below:

Month/Year--------Court-------Result (Guilty, Not Guilty, Nolo)

Are you currently on probation or parole?	Yes No
If "yes", where?
If "yes", for what offense(s)?
Other Tickets / Charges received with this DUI (check all that apply):	Failure to Maintain Lane Speeding Illegal U-Turn Running Red Light or Stop Sign Defective Equipment No Proof of Insurance Failure to Yield Other (Please specify below...)

Please specify other charges not listed above

Why were you stopped/arrested, according to officer?

Was there an accident?	Yes No Not Sure
Was anyone injured? (check all that apply):	No one was hurt/Not applicable Myself Passenger(s) in my vehicle Passenger(s) in another vehicle Pedestrian Not Sure
Were you stopped at a roadblock?	Yes No
Were you given field sobriety tests at the location where you were stopped?	Yes No Don't recall I Refused
Which field sobriety tests were you given? (Check all that apply)	Hand held Breath Test Walking heel to toe One-Leg Stand Follow-the-Pen-With-Eyes Say the Alphabet Touch Your Nose Other (Please specify below...)
Please specify other tests you took, that are not listed above
Did officer advise you that field tests were 100% optional and that no penalty would result from not doing them?	Yes No
Were you videotaped at any point during your arrest?	Yes No Not Sure
Did you take breath test?	Yes No, I Refused No, Test Was Not Offered to Me No, I Was Given a Blood Test I was given all three test--blood, breath and urine Not Sure

WARNING: IF YOU REFUSED THE TEST OR WERE CHARGED WITH REFUSING THE TEST YOU COULD FACE AN AUTOMATIC SUSPENSION OF YOUR LICENSE FOR ONE OR MORE YEARS. DEPENDING ON YOUR STATE LAW, YOU LIKELY HAVE A LIMITED NUMBER OF BUSINESS DAYS FROM THE DATE OF YOUR ARREST TO FILE AN APPEAL AND A "REQUEST FOR HEARING" WITH YOUR STATE'S DEPARTMENT OF PUBLIC SAFETY IF THIS OPTION IS AVAILABLE AT ALL IN YOUR STATE. LIKEWISE, IF YOU SUBMITTED TO A TEST WHICH YIELDS A RESULT OF 0.08 GRAMS OR MORE (EVEN LESS IF UNDER 21 OR OPERATING A COMMERCIAL VEHICLE), YOU MAY ALSO BE SUSPENDED FROM DRIVING FOR 1 TO 5 YEARS. CALL OUR OFFICE IMMEDIATELY FOR ASSISTANCE! 1-888-DUI-CHARGE (1-888-384-2427)

If you took a breath test you should POSSESS a print-out of the two test samples. List your breath test results here:	Sample #1 Sample #2
Blood test results (if known)	Check here if test results are pending
Name of testing officer
Name of arresting officer
Name of police department
Street or location where stopped
County where stopped
Was your car towed?	Yes No
Who authorized the tow truck?	I Did Officer Did Not Sure
Who posted bond?	I Did Bonding Company Family Member/Friend Other
Amount of bond
Were there any witnesses with you who could testify for you?	Yes No
At any time during your arrest did you ever ask for or inquire about getting your own independent blood, breath or urine test?	Yes No
Did you get an independent blood, breath or urine test?	Yes No
If "yes", what was the result?	Check here if test results are pending
Did you ever ask to call an attorney?	Yes No
If "yes", when (give details)?

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