First Name
Last Name
Address 1
Address 2
City
State	Please Choose AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
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	Please Choose Pager Cellular Family Member/Friend Business Other
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 Choose Alta Vista Atlanta Bar website Attorney Find Excite Hotbot Infoseek Lawyerfind Network Legal Dot Net Lycos Referred by someone Starting Point Webcrawler West attorney listings Yahoo Other (Please specify below...)
Please specify how you found us, if not listed above
Employment/Profession
Position
Driver's license required for your job?	Yes No
Date of Arrest	--Select-- January February March April May June July August September October November December --Select-- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 --Select-- 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Time of Arrest	00 01 02 03 04 05 06 07 08 09 10 11 12 : 00 15 30 45 AM PM
Day of the Week	--Select-- Monday Tuesday Wednesday Thursday Friday Saturday Sunday
State Where Arrested	Please Choose AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
City Where Arrested
County Where Arrested
Court Date (leave blank if unsure)	--Select-- January February March April May June July August September October November December --Select-- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 --Select-- 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Time of Court	00 01 02 03 04 05 06 07 08 09 10 11 12 : 00 15 30 45 AM PM
Name of Court
Driver's License #
Valid at time of arrest?	Yes No
Commercial license?	Yes No
State where licensed	Please Choose AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Date of Birth
Is this your first OUIL in your lifetime--anywhere, anytime?	Yes No
If you have had prior OUILs please list them below:	Please Choose AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

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

Are you currently on probation or parole?	Yes No
If "yes", what court?
If "yes", what offense?
Other Tickets/Charges received with this OUIL/OWI (check all that apply):	Weaving/unsafe lane change Speeding Driving on suspended license License not in possession Open container Illegal U-Turn Running Red Light 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
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
What admissions, if any, did you make to the police officer about your consumption of alcohol?
Were you given field sobriety tests at the location where you were stopped?	Yes NoDon't Recall Refused
Which field sobriety tests were you given? (Check all that apply)	Handheld Breath Test Walk-and-turn 9 steps 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 tests were100% optional and that no penalty would result from not doing them?	Yes No
Did you take breath test?	Yes No, I Refused No, Test Was Not Offered to Me No, I Was Given a Blood Test Not Sure

WARNING: IF YOU REFUSED THE TEST OR WERE CHARGED WITH REFUSING THE TEST YOU FACE AN AUTOMATIC SUSPENSION OF YOUR LICENSE FOR SIX MONTHS TO ONE YEAR. YOU HAVE 14 DAYS FROM THE DATE OF YOUR ARREST TO FILE AN APPEAL AND "REQUEST FOR HEARING" WITH THE DRIVER LICENSE APPEAL DIVISION. CALL OUR OFFICE IMMEDIATELY FOR ASSISTANCE!

If you took a breath test you should have a print out of the two test samples. List your breath test results here:	Sample #1 Sample #2
Name of testing officer
Blood test results	Check here if test results are pending
Name of arresting officer
Name of police department
Street or location where stopped
County where stopped
Was your car towed?	Yes No
Was bond posted for your release?	Yes No
Amount posted
Was the bond posted by a bail bondman?	Yes No
Were there any witnesses with you who could testify for you?	Yes No
If you took a breath test, at any time 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 or urine test?	Yes No
If "yes", what was the result?	Please Choose Positive Negative Check here if test results are pending
Did you ever ask to call an attorney?	Yes No
If "yes", when (give details)?
Were you advised of your Miranda rights?	Yes No

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