PERSONAL INFORMATION (optional):
First Name:
Last Name:
Age:
Home Phone:
OK to leave message on home phone?
(Select)
Yes
No
Cell Phone:
OK to leave message on cell phone?
(Select)
Yes
No
Work Phone:
OK to leave message on work phone?
(Select)
Yes
No
Other:
OK to leave message here?
(Select)
Yes
No
Email:
OK to email?
(Select)
Yes
No
Best contact #?
(Select)
Cell Phone
Home Phone
Work Phone
Email
Other Phone
Fax
ANY,
Best time to call?
DRIVER’S LICENSE STATUS:
What was your driver’s license Status at time of arrest?
(Select)
Valid WA License
Valid Other State
Suspended
Revoked
Expired
Other
Need license for job?
(Select)
Yes
No
CDL/endorsements?
(Select)
CDL
Pilot
Motorcycle
Other
PRIOR DUIs:
Ever been arrested for
(Select)
Yes
No
Ever done a deferred
(Select)
Yes
No
DEPARTMENT OF LICENSING:
Officer notify you of
(Select)
Yes
No
Don’t Know
Requested a DOL hearing?
(Select)
Yes
No
DOL hearing date:
DOL
COURT INFORMATION:
Received a court date?
(Select)
Yes
No
Don’t Know
Court location?
(Select)
Snohomish County – Everett
Snohomish County – Evergreen
Snohomish County – Cascade
Snohomish County – South
King County – RJC
King County – Seattle
King County – East
King County-Redmond
King County – Burien
Algona
Anacortes
Arlington
Auburn
Bainbridge Island
Bellevue
Bellingham
Black Diamond
Blaine
Bothell
Bremerton
Brier
Burien
Burlington
Camano Island
Carnation
Clyde Hill
Concrete
Darrington
Des Moines
Duvall
Edmonds
Everett Municipal
Federal Way
Fife
Fircrest
Gold Bar
Granite Falls
Index
Issaquah
Kenmore
Kent
Kingston
Kirkland
LaConner
Lacey
Lake Forest Park
Lake Stevens
Lakewood
Lynnwood
Maple Valley
Marysville
Medina
Mercer Island
Mill Creek
Monroe
Mount Vernon
Mountlake Terrace
Mukilteo
Newcastle
Normandy Park
North Bend
Olympia
Pacific
Redmond
Renton
Sammamish
SeaTac
Seattle
Sedro Woolley
Shoreline
Skykomish
Snohomish Municipal
Snoqualmie
Stanwood
Sultan
Tukwila
Tumwater
Woodinville
Woodway
Yarrow Point
Court date:
Court time:
Offense charged?
(Select)
D.U.I.
Minor D.U.I.
Vehicular Assault
Reckless Driving
Negligent Driving 1
Hit and Run
Other
Don’t Know
Infractions issued:
(Select)
No
Speeding
Failure to Stop
Lane Violation
No Turn Signal
Expired Tabs
Defective Equipment
No Headlight
Other
Don’t Know
Other charges:
YOUR DUI CASE INFORMATION:
Date/Time of arrest:
City of arrest:
Arresting agency:
Arresting officer:
Read your rights?
(Select)
Yes
No
Don’t Know
Ask for an attorney?
(Select)
Yes
No
Don’t Know
Accident?
(Select)
Yes
No
Injuries?
(Select)
Yes, I Was Injured
Yes, Someone Else
No
Don’t Know
Did you do the roadside “sobriety” tests?
(Select)
Yes
No
Officer tell you they were voluntary?
(Select)
Yes
No
Don’t Know
Where were these tests conducted:
(Select)
Highway Shoulder
Street
Parking Lot
Sidewalk
Gravel Lot
Other
Take a handheld breath test (PBT)?
(Select)
Yes
No
PBT Results:
Did you take a breath or blood test?
(Select)
Yes, Breath
Yes, Blood
Yes, Both
No
Don’t Know
Breath Sample #1:
Breath Sample #2:
Blood results:
Receive written warnings (ICW)?
(Select)
Yes
No
Did you obtain an independent blood test?
(Select)
Yes
No
Results:
Any jewelry or other foreign objects in mouth?
(Select)
Tongue/Cheek Stud
Lebret
Braces
Gum
Other
No
Taken to jail?
(Select)
Yes
No
Bond posted?
(Select)
Yes
No
Released by Judge
Ankle Bracelet
Car towed?
(Select)
Yes
No
Given ride home?
(Select)
Officer
Passenger
Friend/Family
Cab
No
Any witnesses?
(Select)
Yes
No
Don’t Know
How did you hear about me?
(Select)
National College of DUI Defense
Attorney Referral
Client Referral
Google
Yellowpages.com
Superpages.com
Nolo.com
Avvo.com
Other Internet Resource
Phone Book
Bar Assocaition Referral
Other
Referring attorney:
Because even if you face a DUI, or other criminal matter, you still deserve respect and fair, thoughtful consideration of your case.
