DUI Free Evaluation Form

Name:
Home Number:
Work Number:
E-mail:
Preferred Contact:
Occupation:
IS A DRIVER'S LICENSE REQUIRED FOR YOUR JOB?
DRIVER'S LICENSE NUMBER:
ISSUING STATE:
DATE OF BIRTH:
WAS YOUR LICENSE VALID AT THE TIME OF THE ARREST?
IS YOUR LICENSE A COMMERCIAL LICENSE?
ARREST INFORMATION
DATE OF ARREST:
TIME OF ARREST:
STATE OF ARREST:
CITY OF ARREST:
COUNTY OF ARREST:
NAME OF COURT OF MUNICIPALITY:
COURT DATE ON CITATION: TIME:
NAME OF ARRESTING OFFICER:
NAME OF ARRESTING POLICE DEPARTMENT:
STREETS OR LOCATION OF TRAFFIC STOP:
COUNTY OF TRAFFIC STOP:
WAS YOUR CAR TOWED:
WAS BOND POSTED FOR YOUR RELEASE:
DID A BAIL BONDSMAN POST THE BOND:
EVENT HISTORY
IS THIS YOUR FIRST DUI-IN ANY STATE OR COUNTRY:
IF YOU ANSWERED "NO" TO THE ABOVE QUESTION, PLEASE LIST THE MONTH, YEAR COURT AND RESULT (GUILTY, NOT GUILTY, NOLO) OF ALL OF YOUR PREVIOUS OFFENSES:
ARE YOU CURRENTLY ON PAROLE OR PROBATION?
IF "YES" - WHAT COURT AND OFFENSE?
WHAT OTHER TICKETS OR CHARGES DID YOU RECEIVE WITH THIS TRAFFIC VIOLATION?
SPEEDING
OPEN CONTAINER
RUNNING A RED LIGHT
FAILURE TO YIELD
WEAVING
UNSAFE LANE CHANGE
NO PROOF OF INSURANCE
NO PROOF OF DRIVER'S LICENSE
DRIVING ON A SUSPENDED LICENSE
ILLEGAL U-TURN
OTHER
WAS THERE AN ACCIDENT THAT OCCURRED AS A RESULT OF THIS DUI?
IF YES, WAS ANYONE HURT:
NO ONE WAS HURT
MYSELF
MY PASSENGER(S)
PASSENGERS IN ANOTHER VEHICLE
A PEDESTRIAN
I'M NOT SURE
WERE YOU STOPPED BECAUSE OF A ROADBLOCK?
DID THE OFFICER PERFORMING THE STOP INFORM YOU THAT THE TESTS WERE COMPLETELY OPTIONAL AND THAT YOU COULD NOT BE PENALIZED FOR REFUSING THE TESTS?
WERE YOU ADVISED OF YOUR MIRANDA RIGHTS?
DID YOU EVER ASK TO CALL AN ATTORNEY?
IF YES, EXPLAIN DETAILS:

TYPE OF TEST(S) PERFORMED DURING THE STOP:
HANDHELD BREATHALYZER
BLOOD TEST
WALK AND TURN 9 STEPS HEEL TO TOE
ONE LEG STAND
FOLLOW THE PEN WITH EYES
RECITE THE ALPHABET
TOUCH YOUR NOSE
OTHER (PLEASE STATE BELOW)
I DECLINED TO HAVE ANY TESTS PERFORMED

OTHER:

BREATHALYZER RESULTS
RESULT #1:
RESULT #2:
BLOOD TEST RESULTS:
TEST RESULTS ARE PENDING:
WERE THERE ANY WITNESSES WITH YOU WHO COULD TESTIFY ON YOUR BEHALF?
PLEASE PROVIDE ANY ADDITIONAL INFORMATION THAT YOU FEEL MAY BE HELPFUL TO YOUR CASE:



Jeffrey S. Posin & Associates
8935 South Pecos Road, Suite 21A
Henderson, Nevada 89074
tel: (702) 396-8888 fax: (702) 837-1650
e-mail: askus@lawfromhome.com