Forms and Questionnaire

Download the Questionnaire

 Driver License Hearing Request form (must be done within 10 days of arrest)

    If you are serious about defending your DUI, record this information while its still fresh in your memory. I will call you after I receive your email report. Please include telephone contact information. It is very important to discuss these matters personally. Submissions without telephone contact information will be discarded.

    Instructions for interview: Please answer the questions as truthfully as possible; do not guess at an answer (approximations are fine, but not as reliable). The results depend on your truthfulness.

    * Required Fields

    If you have been arrested for DUI in the last 10 years, please provide the date, the Court, and what city and state where the prior DUIs took place.





    Your Current Arrest Matter:

    Date of Your Current Arrest?*

    Place of your Current Arrest?*

    Arresting Agency?*

    Think carefully about these next few questions:

    Explain why the officer pulled you over and list other charges you were cited for?

    If it is alleged that you drank alcohol, explain how much you drank and over what time period.

    If it is alleged that you were impaired by legal or illegal drugs, what drugs/medication had you consumed within 30 days prior to your arrest?

    What field sobriety tests do you remember taking? (i.e. Eye test, Walk the Line Test, One Leg Stand Test, etc.)

    If you took a portable breath test, did the officer tell you the result?


    If you took an intoxilyzer test, usually at the station or the jail but sometimes on scene, what was the result of that test?

    If you took a blood test, did the arresting officer obtain a warrant?


    Did you take any other chemical tests? (i.e. urine)

    When you were arrested, were you placed in the back seat of the car and transported to the jail or station?

    If you have a Court date set, what is the date?

    If you have requested a Drivers License Hearing, when did you send it in and by what means?

    Provide a brief narrative of what happened?

    Contact Information:



    Your Home Address:*

    Zip Code:*

    Primary Phone:*

    Secondary Phone:

    Cell Phone:

    Fax Number:

    Contact Preference (when is the best time to contact you)?*

    Date of Birth:*

    Drivers License Number:*


    Annual Income:*

    Place of Employment:*



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