Free Case Evaluation

Full Legal Name:

Name You Go By:

Birth Date:

Home Telephone:

Business Telephone:

Cell Number:

E-mail Address:

Place of Employment:

Job Title:

The Charge You Were Arrested For:

Have you ever been charged with, or convicted of, a crime in the past? ?

If so, please state when, where and the nature of the charge:

Name, Address and Phone Number of Alternate Contact:

How Did You Hear About Us:

DUI ONLY

Date of Arrest:

Drivers License Number:

Did you submit a breath test?

If yes, what were the results of the breath test?

Have you ever been charged with, diverted on, or convicted of a DUI before?

Finally, please give us a summary of the reason you were stopped. Be sure to include any facts unique to your case or things you think we should know:

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