GENERAL INFORMATION                              

Full Legal Name:

Address:

City:

State:

Zip Code:

*Main Phone:

Alternate Phone:

*E-mail Address:

What do you want to do with your case? I want to explore possible defenses to protect my rights. I want a lawyer to get me a reduction if possible and walk me through a plea. I want to fight the case, and I am willing to go to trial if feasible. I cannot afford a conviction under any circumstance.

After you have entered your contact information, you can submit this form. We encourage you to complete the rest of this form so that we can accurately evaluate your case.

                              BACKGROUND INFORMATION                              

What is your age?

What is your gender? Male. Female.

Approximate weight on date of arrest?

How frequently do you drink alcohol?

What is your marital/family status? Single. Single with minor children. Maried - no minor children. Married with minor children at home. Divorced/Separated - no minor children. Divorced/Separated with minor children. Other.

What is your occupation?

Do you have a CDL? Yes, and I drive for a living. Yes, but I do not use it. I have a chauffeur's license. No.

Was your license valid on the date of arrest? Yes. Restricted. No.

If your driver's license is from any state other than Michigan, please specify where you are licensed: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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

Is this your first arrest for DUI/DWI/Drunk Driving in your lifetime-anywhere? Yes Don't Know No

Please list all prior DUI/DWI/Drunk Driving Arrests (even if dismissed) below, including year, city/state, and outcome (if known):

Are you currently on probation/parole for any reason? Yes No

     If "yes", for what offense(s):

                              CASE INFORMATION                              

Date of Arrest:

Time of Stop:

Time of Arrest:

City/Town/Municipality Where Arrest Occurred:

District/Circuit Court Number or Location:

Court Date:

Where were you stopped:

Why were you stopped according to the police officer?

Are there any witnesses who were with you before or during your driving that can testify for you? Yes Don't Know No

Do you know if the officer recorded your driving on video? Yes Don't Know No

Was there an accident? Yes No

Was anyone injured? (Check all that apply):

      No one was hurt
      Myself
      Passenger in my vehicle
      Passenger in another vehicle
      Pedestrian
      Not Sure

                              FIELD SOBRIETY TESTING                              

Did you take any field sobriety tests? Yes No, none were offered. No, I refused to take any roadside tests.

Which tests were you given? (Check all that apply):

      Horizontal Gaze Nystagmus (eye test)
      Walk and Turn / Heel to Toe
      One Leg Stand
      Finger to nose
      Finger Count (1,2, 3, 4, 4, 3, 2, 1)
      Counting
      Pick a Number
      Alphabet
      Romberg (head tilt / eyes closed)
      PBT

                              MEDICAL / PHYSIOLOGICAL                              

Please describe your overal state of health: Very fit and healthy Average Some health problems Poor

Were you under a doctors care on the date of your arrest? Yes No

Are you prescribed drugs or medications that you take on a regular basis? Yes No

     If "yes", please specify:

Do you have any prior injuries disabilities that might have affected your driving or performance of field sobriety tests? Yes No

     If "yes", please specify:

As to the following conditions, please check all that apply:

      Diabetic
      Hypoglycemic or Hyperglycemic
      Dentures, Retainer, or Tongue Ring
      Glasses / Corrective Lenses
      Conjunctivitis
      Dyslexia
      Glaucoma
      Lazy Eye or Cross Eyed
      Blind in one eye
      Acid Reflux Disease (GERD)
      Take heartburn medication
      Esophageae hernia
      Ulcers / Problems with stomach
      Exposure to toluene, acetone, ether or other chemicals
      Use an inhaler
      Emphysema
      COPD
      Asthma
      Prior head injury
      Hearing aid
      Hearing loss
      Low carb diet / Atkins diet
      Back / Leg / Other Muscular Problems
      Ataxia
      Ear infection (at or around time of arrest)
      Stroke
      High Blood Pressure
      Anxiety attacks
      Attention Deficit Disorder

                              CHEMICAL TESTS                              

Did you take a preliminary breath test on the scene? Yes Don't Know No

     Result:

Was there a breath test at the police station? Yes Don't Know I refused to take it No

     Result:

Was there a blood test taken? Yes Don't Know I refused to take it No

     Result:

If you refused to submit to a Datamaster and/or blood test, did the police officer serve you with a Notice of Refusal? Yes Don't Know No

Did the police seek a search warrant to draw blood? Yes Don't Know No

                              ADDITIONAL INFORMATION                              

Please provide us with any additional information you would like to share: