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Street address: |
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City: |
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State: |
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Zip: |
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Home phone: |
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Cell phone: |
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Work phone: |
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Fax: |
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Date of birth: |
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*Email address: |
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| About the arrest: |
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Date of arrest: |
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| Court date on ticket: |
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Next court date: |
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Arresting agency: |
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City of arrest: |
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*County of arrest: |
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Alleged charges: |
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Plea, if applicable: |
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| Were you involved in an accident? |
No, I was not involved in an accident
Yes, I was involved in an accident
If yes, was anyone hurt? (Please provide brief details) |
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Did the police officer give you any reasons for stopping you?
If so, please note them in the box below. |
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| What really happened? |
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Did police administer any field sobriety tests at the time of your arrest?
Please check all that apply. |
Full alphabet - forwards or backwards
Partial alphabet
Counting
Finger-to-nose
Horizontal gaze nystagmus - watching a pen or light move horizontally
Vertical nystagmus - watching a pen or light move vertically
Walk and turn, or heel-to-toe
I refused to submit to field sobriety tests
I cannot recall if sobriety tests were administered
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Did police administer breath or blood tests?
Please check all that apply. |
I refused to submit to a breath or blood test I was forced to submit to a blood test Breath test at the scene of the arrest Breath test at police station Blood test at a hospital
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| If police conducted tests, what were the results? |
| Blood test results: |
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| Breath test results: |
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| Did you request any additional tests? |
No. I did not request additional tests.
Yes, I requested additional tests, but they refused.
Yes, additional tests were conducted;
the results were:
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| Do you have any prior charges or convictions? |
No. I do not have any prior charges or convictions.
Yes, 1 prior DUI, but it was more than 10 years ago.
Yes, 1 prior DUI less than 10 years ago.
Yes, 2 prior convictions
Yes, 3 prior convictions
Yes, 4 prior convictions
Yes, 5 prior convictions
Yes, 6 prior convictions
Yes, 7 prior convictions
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| If you were previously convicted, were you represented by attorney? |
Yes, I was represented for all prior convictions
No, I was not represented for any prior conviction
No, I was not represented for at least one prior conviction
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| Do you have a driver's license? |
Yes, I have an Alaska driver's license
Yes, I have a driver's license from another state
No, I do not have a valid driver's license
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| Were miranda rights read to you? |
Yes, miranda rights were read to me
No. Miranda rights were not read to me.
I do not recall whether or not miranda rights were read to me.
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| Do you have an attorney? |
No. I do not have an attorney.
I qualify for a public defender, but I want to hire a private attorney.
I do not qualify for a public defender.
I don't know if I qualify for a public defender.
My annual income is:
I have an attorney.
My attorney's name is: |
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| How may we help you? |
I want to hire your firm
Please call me regarding my case.
I am contacting you about a relative or significant other
I want a second opinion
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How would you like to be contacted? |
Email
Phone |
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Fax
Postal mail |
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If there are any other details that may be useful in assessing your case,
please provide them below. |
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