Potential Client Questionnaire

First Name

Last Name

Address 1

Address 2

City ST Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

ZIP Code

Phone #

Okay to call you at this number? Yes No

Alternate Phone#

Okay to call you at this number? Yes No

Alternate number is a Pager Cellular Family Member/Friend Other

FAX

Okay to fax you at this number? Yes No

Email

Okay to email you at this address? Yes No

How did you find this web site? Alta Vista Atlanta Bar website Attorney Find Excite Hotbot Infoseek Legal Dot Net Lycos Referred by someone Starting Point Webcrawler West attorney listings Yahoo Other (Please specify below...)

Please specify how you found us, if not listed above

Are you mainly interested in fighting your DUI, or do you want to
plead nolo or guilty?

  Fight the case Plead Nolo Plead Guilty Not Sure

Date of Arrest Time of Arrest

Day of the Week Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Court Date (leave blank if unsure) Time of Court

Name of Court

Driver's License #

State Where Licensed Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Date of Birth

Is this your first DUI in your lifetime--anywhere, anytime?

Yes No

If you have had prior DUIs please list them below:

Month/Year------Court-------Result (Guilty, Not Guilty, Nolo)

Are you currently on probation or parole? Yes No
If "yes", where?

Other Tickets/Charges received with this DUI (check all that apply):

• Failure to Maintain Lane
• Speeding
• Illegal U-Turn
• Running Red Light
• Defective Equipment
• No Proof of Insurance
• Failure to Yield
• Other (Please specify below...)

Please specify other charges not listed above

Why were you stopped/arrested, according to officer?

Was there an accident? Yes No Not Sure

Was anyone injured? (check all that apply):

• No one was hurt/Not applicable
• Myself
• Passenger(s) in my vehicle
• Passenger(s) in another vehicle
• Pedestrian
• Not Sure

Were you stopped at a roadblock? Yes No

Were you given field sobriety tests at the location where you were stopped?
Yes No Don't recall Refused

Which field sobriety tests were you given? (Check all that apply)

• Handheld Breath Test
• Walk-and-turn 9 steps heel to toe
• One-Leg Stand
• Follow-the-Pen-With-Eyes
• Say the Alphabet
• Touch Your Nose
• Other (Please specify below...)

Please specify other tests you took, that are not listed above

Did officer advise you that tests were 100% optional and that no penalty would result from not doing them? Yes No

Did you take breath test?

• Yes
• No, I Refused
• No, Test Was Not Offered to Me
• No, I Was Given a Blood Test
• Not Sure

WARNING: IF YOU REFUSED THE TEST OR WERE CHARGED WITH REFUSING THE TEST YOU FACE AN AUTOMATIC SUSPENSION OF YOUR LICENSE FOR ONE OR MORE YEARS. YOU HAVE 10 BUSINESS DAYS FROM THE DATE OF YOUR ARREST TO FILE AN APPEAL AND "REQUEST FOR HEARING" WITH THE DEPARTMENT OF PUBLIC SAFETY. LIKEWISE, IF YOU SUBMITTED TO A TEST WHICH YIELDS A RESULT OF 0.100 GRAMS OR MORE, YOU CAN ALSO BE SUSPENDED FOR 1 TO 5 YEARS. CALL OUR OFFICE IMMEDIATELY FOR ASSISTANCE!

If you took a breath test you should have a print out of the two test samples. List your breath test results here.

Sample #1 Sample #2

Blood test results Check here if test results pending

Name of testing officer

Name of arresting officer

Name of police department

Street or location where stopped

County where stopped

Was your car towed? Yes No

Who called the tow truck? I Did Officer Did Not Sure

Who posted bond? I Did Bonding Company Family Member/Friend Other

Were there any witnesses with you who could testify for you? Yes No

At any time during your arrest did you ever ask for or inquire about getting your own independent blood, breath or urine test? Yes No

Did you get an independent blood, breath or urine test? Yes No
If "yes", what was the result? Check here if test results are pending

Did you ever ask to call an attorney? Yes No

If "yes", when (give details)?

Additional comments: