Basic Information

Full Name: (including middle name)
Date Of Birth:

Contact Information

Home Phone: ( ) - Best time to call:
Cell Phone: ( ) - Best time to call:
Work Phone: ( ) - ext: Best time to call:
E-Mail Address:
Street Address: (Please include room/apartment number and zip code)
City: State: Zip:

Driver License

California Driver License Number:
Is your license a commercial license?

Citizenship

Are you a US citizen?
If "no" to the above question, please explain immigration status:

Past DUI Arrests/Convictions

Have you ever been cited for OR arrested for OR convicted of a DUI in the past in any state (regardless of whether charges were filed or not against you):
If yes, describe date of citation OR arrest (month, day, year), county/state of citation OR arrest and charge(s):
Was/were the conviction(s) a misdemeanor or felony? Please explain:

Past Criminal Arrests/Convictions

Aside from any DUI arrests or convictions, do you have any prior criminal record meaning citations for (even if no conviction), arrests (even if no conviction) or conviction
If yes, please indicate the year/county/state/type of conviction and whether it was a felony or misdemeanor

Present DUI Arrest

IF YOU WERE ARRESTED IN ALAMEDA COUNTY: please provide CEN NUMBER from your booking sheet:
IF YOU WERE ARRESTED IN SANTA CLARA COUNTY: please provide provide CEN NUMBER from your booking sheet:
Location of arrest (name of street or highway, city, county):
Name of Police Department that involved in your arrest:
Date and time of arrest:
Time:
Did you take a blood, breath, or urine test at the station?
If yes, what was the result of the test?
Did you blow into a preliminary alcohol screening device at the side of the road?
If yes, what was the test result (number) if you know?
Were any children under 14 in the vehicle with you at the time of the DUI?
Did police say you were speeding MORE THAN 30 miles an hour over the posted limit on a highway or MORE THAN 20 miles an hour over the posted speed on a street?
Did police claim, after your arrest, that you refused or failed to complete a blood, breath or urine test?
Did police charge you with any other crime other than a DUI (ie hit/run, suspended license, false information to police, etc)?
If yes, what were the other charge or charges?
Was your license at the time of the DUI suspended or revoked?

Court Information

Date (month/day/year) of issuance of suspension/revocation order and temporary license (pink document you received from police, date is in lower left hand corner):
Date & time when you must appear for court:
Time:
I don't know
Place (city/county) where you must appear for court:

Hearing Information

Have you contacted the DMV already to request a hearing?
If yes, what kind of hearing:
If yes, what are the date and time of the hearing:
If yes, who is the hearing officer (list name):
If yes, have you received discovery yet?
If yes, please fax it immediately to Mark Blair (650) 344-4353

Car Accident

Were you involved in an accident?
If yes, what did you hit?
If yes, was anyone injured other than yourself?
If yes, describe the other person's or persons' injuries:

Alcohol Details

How much alcohol did you drink during the last 12 hours before you drove? Please describe what you drank, when you drank it, and how much each drink was
Did you feel the effects of the alcohol while you drove?
Did you take any medication within 24 hours of driving? If so, please state name, dosage
Did you use any non prescription drugs within 72 hours of driving? Please include any illegal drugs and describe amount and date/time consumed.

Police Stop

Did police ever tell you why they stopped you?
If police DID tell you why they stopped you, what did they say?
If police DID NOT tell you why they stopped you, do you feel that you were violating any vehicle code sections (example: speeding, changing lanes without signaling, weaving)?
At the time that police stopped you, did you know if your car had any apparent problems (example: inoperable tail lights) and if so, what was the problem?
Did you do field sobriety tests after being stopped?
Were you alone in the car?
If no, please give name, address, telephone number with area code of passengers(s)

Background Information

What is your education level?
Do you have any problems reading or writing? If so, describe.
Do you have any significant physical problems or limitations (including but not limited to any handicaps)? If so, describe.
Do you have now or have you ever had in the past any mental problems? If so describe the name, date diagnosed, who diagnosed you, any hospitals where you were treated, and any medication that you received.
Are you taking any medication other than aspirin? If so, describe (also indicate if it makes you drowsy).
Do you have any drug and/or alcohol problem? If so, describe.
Have you ever attended any drug or alcohol program (in patient or out patient)?
If yes, please indicate the name, address, telephone number with area code and date that you begin and ended the program(s)
List all your significant, positive accomplishments (post high school education degrees, volunteer/community service, charitable donations, etc).