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Your Contact Information

Who referred you to us?

Referred by
Name *
Address
Address 2
city
State
Zip
email *
Telephone (home)
Telephone (work)
Telephone (cell)
Can we call you at work?
Employment
Employer's address

Licenses You Hold

Leave blank if no

Driver License #

Leave blank if no

CDL?

Leave blank if no

Pilot License #

Leave blank if no

Professional License
Type of Profession

Your DUI Case

This section pertains to the incident for which you were charged, and for which I will be representing you.

State of Stop
County of Stop
Police Agency
Time of Stop
Was an accident involved?
Why were you stopped
Police Officer's first comments
Did Police ask how much you had to drink
Did you answer
What did you tell the Officer
What and how much did you drink/smoke/other
Were Field Test Performed
Were you informed they are voluntary
Were Miranda rights read to you
What field tests were administered HGN-eye One Leg Stand Count to 30 Walk and Turn Finger to Nose ABC�s Five finger dexterity Portable Breath Test
What were the results of the Field Tests
Were You Cuffed
At what point were you arrested
Were you read implied consent rights

Was an explanation of right to refuse, bac over .08 or independent test after rights read to you?

Explanation of right to refuse
Was the following read to you

Over/Under 21 : "Georgia law requires you to submit to state administered chemical tests of your blood, breath, urine, or other bodily substances for the purpose of determining if you are under the influence of alcohol or drugs. If you refuse this testing, your Georgia driver's license or privilege to drive on the highways of this state will be suspended for a minimum period of one year. Your refusal to submit to the required testing may be offered into evidence against you at trial. If you submit to testing and the results indicate an alcohol concentration of 0.08(over 21) /0.02 (under 21) grams or more, your Georgia driver's license or privilege to drive on the highways of this state may be suspended for a minimum period of one year. After first submitting to the required state tests, you are entitled to additional chemical tests of your blood, breath, urine, or other bodily substances at your own expense and from qualified personnel of your own choosing. Will you submit to the state administered chemical tests of your (designate which tests) under the implied consent law?"

Yes/No/Don't Know
Did you refuse the test
Did you request explanation
Did you ask for an independent test
Reason given for refusal
Did you blow in to the Intoxilyzer 5000
Where
Who was the operator
What were the results
Did you take a blood test
How was blood taken
How was blood sent to lab

Before Sending This Form

Before you click "Submit" please make sure you have answered all questions to the best of your recollection of the stop, and the arrest. Complete and correct information will greatly assist us in preparation for your defense.