DUI Information Form
First Name:
Last Name:
Address:
City:
State:
Zip Code:
Daytime Phone:
Evening Phone:
E-Mail Address:
Cell Phone/Pager:
Did you have a valid license?                  Yes No
Did you have valid insurance? Yes No
Did the officer see the vehicle moving? Yes No
Have you been convicted of DUI or a Wet Reckless within seven years of this arrest?  If so, how many times, when, which court(s)? Yes No
Were you involved in an accident in this case?
Yes No
What was the reason the officer gave for pulling you over in this case?
What were the cross streets where you were pulled over by the police officer?
What city and county were you pulled over in?
What did you tell the police about what you had to drink and when you consumed the drinks?
What else did you tell the officer concerning drinking or drug use?
Were you under 21 years of age at the time of the arrest?
Yes No
Any mechanical problems with your vehicle?
Yes No
Was there a child under 14 years of age in the car? Yes No
Were you speeding more than 20 mph over the posted limit? Yes No
If you were involved in an accident, were there any injuries to anyone in your vehicle or the other party's vehicle? Yes No
Did the officer ask you to perform a field sobriety test? Yes No
Did you perform a field sobriety test? Yes No
Did the officer advise you of your Miranda rights? Yes No
If so, did you waive your Miranda rights? Yes No
Did the officer ask you to blow into a hand held breath device at the scene? Yes No
If so, did the officer advise you that you had the right to refuse that on scene breath test? Yes No
If so, how many times did you blow into that on scene breath test?
At your arrest, were you advised that you had a choice between a blood, breath or urine test? Yes No
If so, which did you take?

Blood

Breath

Urine

None

What was the result of the test?
If you took a breath test, how many times did you blow into the machine?
Check each box that applies:

    I'm Diabetic                   I'm Epileptic                   I am currently under a doctor's care.              

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