First Name:
Last Name:
Address 1:
Address 2:
City:
State:
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Zip:
Phone Number:
Okay to call you at this number?
Yes
No
Alternate Phone:
Alternate number is a:
Choose One
Pager
Cellular
Family/Friend
Business
Other
Okay to call you at this number?
Yes
No
Fax Number:
Okay to Fax?
Yes
No
Email:
Okay to Email?
Yes
No
How did you find this web site?
Choose One
Google
Alta Vista
Excite
Atlanta Bar Website
AttorneyFind.com
AttorneyPages.com
Hotbot
Infoseek
Lawyers.com
Legal Dot Net
Lycos
Referred by someone
Starting Point
Webcrawler
West attorney listings
Yahoo
Other (Please specify...)
Please specify how you found us (if not listed above):
If you have been charged with a crime, or are under investigation for a crime, what are the charges?
Date of Arrest:
Time of Arrest:
Day of the Week:
Choose One
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
City Where Arrested:
County Where Arrested:
Court Date (leave blank if unsure):
Time of Court:
Name of Court:
Driver's License Number:
State Where Licensed:
Choose One
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
D.C
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Date of Birth:
If you have been charged with DUI/DWI, is this your first DUI/DWI in your ifetime--anywhere, anytime?
Yes
No
Are you mainly interested in fighting your DUI, or do you want to plead nolo or guilty?
Choose One
Fight the case
Plead Nolo
Plead guilty
Not sure
If you have had prior DUI's/DWI's please list them here:
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/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 arrested for DUI / DWI, you have 30 days
from the date of your arrest to request a hearing with the
Washington Department of Licensing. Failure to request a hearing
within the allotted time will result in the immediate suspension
of your license, up to 2 years if you refused a Breath Test.
CALL OUR OFFICE IMMEDIATELY FOR ASSISTANCE!
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 v_bond_post 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)?
Additional Comments Are Welcome: