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City
State
Zip Code
Home Phone
Work Phone
Cell
What is your current occupation?
(This can be an important because of the adverse consequences of a conviction.)
Do you have a CDL?
yes
no
Do you have a professional license threatened by a DUI conviction?
yes
no
What is the date of this offense?
At what time were you arrested?
Full Name
Street Address
What time were you stopped by the police?
(This can be found on your temporary driver's license.)
Why were you stopped by the police?
(Be specific.)
City
and
police department
handling the arrest:
What are the current charges?
(List all offenses, i.e. OWI 1st, PBT refusal, driving while suspended, etc.)
Feel free to provide any additional details about you or your case. You may also provide an email address in this section if you prefer to be contacted by email.
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