First Name:  
Middle Name:  
Last Name:  
Home Phone: ( ) - Best time to call:
Cell Phone: ( ) - Best time to call:
Work Phone: ( ) - ext: Best time to call:
E-Mail Address: (If none type: none)
E-Mail Address 2: (optional)
Street Address: (Please include apt. number and zip code)
City:  
State & Zip  
California Driver License Number:
At the time of your DUI, did you have a valid, unsuspended California driver license?
If "no", did you have a valid, unsuspended out of state license?
Date Of Birth:
Are you a US citizen?
If "no" to the above question, please explain immigration status:
Name of Police Department involved in your arrest: (If you don't know, type "Unknown")
Date of issuance of suspension/revocation order and temporary license (pink document you received from police, date is in lower left hand corner):
I don't know
Date & time when you must appear for court:
Time:
I don't know
Place (city/county) where you must appear for court:
Did you take a blood, breath, or urine test at the station?
Have you ever been cited for OR arrested for OR convicted of a DUI in the past in any state (regardless of whether or not charges were filed against you):
If "Yes" to the above question:
How many times?
Year of conviction(s): (Separate with comma, type "Unknown" if you do not know)
State of conviction(s): (Separate with comma, type "Unknown" if you do not know)
Felonies or convictions? (Separate with comma, type "Unknown" if you do not know)