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What is your full name? (First & Last)
Street address
City, State & Zip Code
What is your email address? 
What is your Date of Birth?
What is the date of the incident?
In what COUNTY did the incident occur?
License & Insurance? (Select)
Children in Vehicle? (Select)
Why were you stopped/detained?  (Select)
Did you admit to drinking/use of drugs?
How much did you drink?
If you are charged with DUI-Drugs:
What is your occupation?
DUI / ARD History? (List ALL, regardless of date)
Criminal Record (other than DUI)
Do you know your blood/breath results?
What is your docket number?
Do you have an attorney?
Most important Attorney Quality:
What is your goal for this case?
Is there ANYTHING else (including any medical issues that you may have) we should know about your case?

How did you learn of our firm?