FREE ONLINE DUI CASE EVALUATION / 
FREE ARD ELIGIBILITY EVALUATION
Complete this form to receive a Comprehensive Case Evaluation 
from a Top-Rated Pennsylvania DUI Defense Attorney.  

 No office visit necessary.  The Evaluation is FREE.  
Our Fees & Payment Plans are AFFORDABLE.  
You will get  a 10% Discount if you retain our services online. 
What is your full name? (First & Last)
Your 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 we should know about you or your case?



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