First name:      Last name: 

Street name/P.O. box: 

City:      State:  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 Washington, D.C. West Virginia Wisconsin Wyoming     Zip code: 

Phone #:      May we contact you through this number? Yes No

Alternate #:      May we contact you through this number? Yes No

Alternate # is a Work Number Pager Cell Phone Friend/Family Member Other

Fax #:      May we contact you at this number? Yes No

E-mail address: 
May we contact you at this address? Yes No

Are you mainly interested in fighting your DUI, or do you want to plead nolo or guilty?
Fight the case Plead nolo Plead guilty Not sure

Date of arrest:      Time of arrest: 

Day of the week:  Sunday Monday Tuesday Wednesday Thursday Friday Saturday -= Please Select =-     Court date:  

Court time:      Court name: 
Driver's license #:      State where 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 Washington, D.C. West Virginia Wisconsin Wyoming

Date of birth: 

Is this your first DUI in your lifetime--anywhere, anytime?  Yes No

If you have had prior DUIs please list them below.
Please include month/year, court, & court results.


Are you currently on probation or parole?  Yes No

Please check below all other tickets/charges received with this DUI:

Reckless driving
Speeding
Illegal U-turn
Running red light
Defective equipment
Careless Driving
Failure to yield
Other (Please specify below)

Please specify other charges not listed above:


Why were you stopped/arrested, according to the officer?


Was there an accident?  Yes No Not sure

Was anyone injured? (check all that apply):

No one was hurt/Not applicable
Myself
Passengers(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
Refused

Check below all field sobriety tests that you were given?

Handheld breath test
Walk-and turn 9 steps heel to toe
One-leg stand
Follow the pen with eyes (Nystagmus test)
Say the alphabet
Touch your nose
Other (Please specify below...)

Please specify other field sobriety tests that you took, which are not listed above.


Did the officer advise you that tests were 100% optional and that no penalty would result from not doing them?  Yes No

Did you take the 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 CHARGE WITH REFUSING THE TEST, YOU FACE AN AUTOMATIC SUSPENSION OF YOUR LICENSE FOR 180 DAYS TO ONE AND ONE-HALF YEARS. YOU HAVE 15 DAYS FROM THE DATE OF YOUR ARREST TO FILE A "REQUEST FOR HEARING" WITH THE DEPARTMENT OF MOTOR VEHCILE, LITIGATION SUPPORT UNIT. LIKEWISE, IF YOU SUBMITTED TO A TEST WHICH YIELDS A RESULT OF 0.100 GRAMS OR MORE OF ALCOHOL IN YOUR BLOOD, BREATH, OR URINE, YOU CAN ALSO BE SUSPENDED FOR 90 DAYS UP TO ONE YEAR. CALL OUR OFFICE IMMEDIATELY FOR ASSISTANCE, 1-888-DWI-DR79. For More Information Please Refer To The Louisiana Implied Consent Law.