Basic Information

Full Name: (including middle name)

Contact Information

Home Phone: ( ) - Best time to call:
Cell Phone: ( ) - Best time to call:
Work Phone: ( ) - ext: Best time to call:
E-Mail Address:
Street Address: (Please include room/apartment number)
City: State: Zip:
Date Of Birth: Age:

Citizenship

Are you a US citizen? If "no" explain your immigration status and country of origin.

County Information

If your DUI occurred in Alameda County, please provide CEN Number from your booking sheet:
If your DUI occurred in SANTA CLARA county please provide CEN Number from your booking sheet:

Drivers License Information

At the time police stopped or contacted you did you have a valid license?
If "no," was it (see drop down box) suspended, revoked, restricted or "I never had a valid license"?
Why was it suspended or revoked?
Driver License State & Number:
Is your license a commercial license? Most persons have a non commercial class c license.
Before your DUI arrest, was your driver's license at any time restricted, suspended, or revoked?
If Restricted, Suspended, or Revoked Before current DUI: Start Date: End Date:

Past DUI Arrests/Convictions

Have you ever been cited for OR arrested for OR convicted of a DUI in the past in any state (regardless of whether charges were filed or not against you)?
If yes, describe date of citation OR arrest (month, day, year), county/state of citation OR arrest and charge(s).
Was/were the conviction(s) a misdemeanor or felony?
Please explain:

Past Criminal Arrests/Convictions

Aside from any DUI arrests or convictions, do you have any prior criminal record meaning citations for (even if no conviction), arrests (even if no conviction) or conviction?
Please indicate the year/county/state/type of conviction and whether it was a felony or misdemeanor:

Present DUI

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Date and time of DUI.
Time (AM or PM):
Have you contacted the DMV already to request a hearing?
What kind of hearing?
What are the date and time of the hearing?

Who is the hearing officer (list name)?
Have you received discovery yet (police report, test results) from the dmv?
If Yes, please fax it immediately to Mark Blair (650) 344-4353.
Name of Police Department that involved in your arrest?
Location of arrest (name of street or highway, city, county)?
Date (month/day/year) of issuance of suspension/revocation order and temporary license (pink document you received from police, date is in lower left hand corner, four to five boxes up from the corner)?
Date & time when you must appear for court?
Time:
I don't know
County Court where the charges are filed?
Were you alone in the car?
If “NO,” please give name, address, telephone number with area code of passengers(s)?
Did police ever tell you why they first wanted to speak with you? (meaning: regardless if police stopped you or if you were not driving but police contacted you at the roadside)
If police DID tell you why they wanted to speak with you, what did they say?
If police DID NOT tell you why they wanted to speak with you, do you feel that you were violating any vehicle code sections (example: speeding, changing lanes without signaling, weaving)?
If "yes", please explain.
At the time that police stopped you, did you know if your car had any apparent problems (example: inoperable tail lights) and if so, what was the problem?
If "yes", please explain.
Were you involved in an accident?
At the time of the accident, did you have insurance to cover third party damages?
If you had an accident, briefly describe how it happened and the position of your vehicle vis a vis the position of the object you hit (example: I rear ended another car. It was parked and unoccupied).
If yes, what did you hit?
If yes, what was the speed of the impact?
If yes, was anyone injured other than yourself?
If yes, describe the other person's or persons' injuries.
IF you had an accident, where there any other persons in EITHER your car OR, if you hit another vehicle, the other vehicle? If so, describe the person(s)'s age and sex and vehicle he/she was in?
If "YES," how many persons were in each vehicle and what were their approximate ages?
Did police say you were speeding MORE THAN 30 miles an hour over the posted limit on a highway or MORE THAN 20 miles an hour over the posted speed on a street?
IF "YES", what was the speed that police claimed you were doing and what was the posted speed?
Did police claim, after your arrest, that you refused or failed to complete a blood, breath or urine test?
IF "YES", did police warn you that if you refused, your license would be suspended for one, two or three years?
If police claimed you refused after your arrest to submit to a blood test, did they obtain a search warrant to forcibly draw your blood?
Did police charge you with any other crime other than a DUI (ie hit/run, suspended license, false information to police, etc)?
What were the other charge or charges?
Did police make you pay bail before they released you?
If Yes, what was the total dollar amount of bail?
What was your height at the time of the DUI?
What was your weight at the time of the DUI?
Describe what you ate in the eight hours proceeding your DUI arrest.
Describe within the 24 hour period leading up to your being stopped/contacted by police, the type of alcohol you consumed, the amount you consumed, the time(s) (from what time to what time) that you consumed it.
Describe what you told police that you consumed within the 24 hour period leading up to your being stopped/contacted by police, as to the type of alcohol you consumed, the amount you consumed, the time(s) (from what time to what time) that you consumed it.
Did you do field sobriety tests after being stopped?
Did you blow into a preliminary alcohol screening device at the side of the road?
If yes, what was the test result (number) if you know?
Did you take a blood, breath, or urine test after your arrest?
If "yes" (if you took a test after your arrest), what test was it?
If yes, what was the result of the test?
Did you take any medication within 72 hours of driving?
If so, please state name, dosage.
Did you use any non prescription drugs within 72 hours of driving?
Please include any illegal drugs and describe amount and date/time consumed.
IF you took medication in combination with alcohol, are you aware of any warnings about taking this particular medication with alcohol?
IF "YES", what do you know about such warnings? (describe):
Did you feel the effects of the alcohol and/or drugs/medication while you drove?
IF "YES", explain how you felt due to the effects of alcohol and/or drug/medicine as you drove.

Background Information

What is your education level?
Do you have any problems reading or writing?
If so, describe.
Do you have any significant physical problems or limitations (including but not limited to any handicaps)?
If so, describe.
Do you have now or have you ever had in the past any mental problems?
If so, describe the name, date diagnosed, who diagnosed you, any hospitals where you were treated, and any medication that you received.
At the time of your DUI, were you taking any medication other than aspirin?
If so, describe (also indicate if it makes you drowsy).
Do you have any drug and/or alcohol problem?
If so, describe.
Have you ever attended any drug or alcohol program (in patient or out patient)?
If yes, please indicate the name, address, telephone number with area code and date that you begin and ended the program(s).
List all your significant, positive accomplishments (post high school education degrees, volunteer/community service, charitable donations, etc).