DUI Questionnaire

Please fill out the information below, so we may better help you.


Name (required)

Street Address (required)

City (required)

State/Province (required)

Zip/Postal Code (required)

Email Adress(required)

Home Phone (required)

May we contact you at this number?
YesNo

Work Phone (required)

May we contact you at this number?
YesNo

How did you find us? (required)


Date of arrest (required)
(mm/dd/yy)

Time of arrest (required)
(am or pm)

Court Date (required)
(mm/dd/yy)

Court Time (required)
(am or pm)


Name of Court (required)

Driver's License Number(required)

State where licensed (required)

Date of Birth (required)
(mm/dd/yy)


Is this your first DUI?
YesNo

If you had prior DUI's/DWI's-please list them below
(Month/Year-Court-(Guilty-Nolo,Not Guilty)


Are you currently on probation or parole?
YesNo

If yes, where and for what?


Name of Arresting Officer

Name of Police Dept.

Why were you stopped according to the officer


Other Charges received with this DUI (multiple selections allowed)

Please specify charges not listed above


Was there an accident
YesNo

Was anyone injured?
YesNo

Were you stopped at a roadblock
YesNo

Which field sobriety test were you given? (multiple selections allowed)


***WARNING***
If you refused the test or were charged with refusing the test you face an automatic suspension of your license for 1 or more years. You have 10 business days from the date of your arrest to file an appeal and request for hearing with the Georgia Department of Motor Vehicle Safety. Likewise if you submitted to a test which yields a result of 0.08% or more (0.02 or more if under 21 and 0.04% or more if operating a commercial vehicle), you may also be suspended from driving for 1 to 5 years. Call our office immediately so we can help preserve your driver's license.

770-513-0113


Name of Police Dept.

If you took a breath test, you should possess a
printout of the two samples.

Sample 1
Sample 2


Street or location where stopped

Was your car towed
YesNo

Who posted bond?

How long were you in custody?

At anytime did you ask for your own independent blood,
breath or urine test?
YesNo

Please explain your request and results


Additional brief comments

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