First Name:
Last Name :
Address (Number, Street, City,
State, Zip):
* Phone:
Ok to call you at this phone ?
Yes No
Alternate Phone:
Ok to call
you at this phone?
Yes No
* E-mail
Address:
How did you hear about us?
How do you want to handle
your D.U.I? (fight, no contest, guilty?)
Fight the case Pleade nolo
Plead guilty
Not sure
Date of incident :
City where incident occurred:
County where incident occurred:
Other Bay Calhoun Gulf
Holmes Washington Unsure
Are you currently on probation:
Unsure Yes No
If yes, where?
If yes, type of charge:
Other DUI DUI Plus Other Charges
Federal Drug Related
Federal Other Felony Drug Related Felony Battery Felony Vop Felony Other Misdemeanor Drug Charge
Misdemeanor Vop Misdemeanor Other Suspended Drivers
License Unsure
Court date (leave blank if
unsure):
Time on date to be at court:
Name of court:
Driver's License Number:
State where licensed :
Date of Birth (mm/dd/yy):
Is this the first DUI/DWI
you've ever gotten? In your whole life?
Yes No
If it is not your first
DUI/DWI, list prior incidents here:
List Month/Year, Court Name and Result please:
Were other tickets or charges
received with your DUI/DWI? If so what are they? (leave
blank if this does not apply)
Was there an accident?:
Yes No
Was anyone hurt in this
accident? List all people hurt in this incident and their
role (ex., passenger in my car, passenger in car
hit by my vehicle, etc)
Were you stopped at a DUI/DWI
checkpoint ?
Yes No
Were you given field sobriety
tests? If so, what type? Please list what you did in each
test.
Did the officer explain
to you that field sobriety tests are 100% optional and that
no penalty would result from not doing them?
Yes No
Were you video-taped at
all during your arrest?
Yes No
Not sure
Did you take a blood, breath
or urine test? List any or all of these you took.
List all other relevant information
here:
WARNING : IF YOU WERE ARRESTED FOR DUI YOUR LICENSE WILL BE SUSPENDED AND YOU HAVE ONLY TEN DAYS TO REQUEST A HEARING WHETHER YOU SUBMITTED TO THE TEST OR REFUSED THE TEST.
THE SUSPENSION MAY BE FROM 6 TO 18 MONTHS AND IS AUTOMATIC UNLESS YOU REQUEST A HEARING WITHIN TEN DAYS FROM THE DATE OF THE TICKET. IF YOU CONTACT MY OFFICE BEFORE THE TEN DAYS HAS ELAPSED MY WELL TRAINED STAFF WILL ASSIST YOU IN REQUESTING THE HEARING AND HELP PROTECT YOUR RIGHT TO DRIVE AT NO OBLIGATION TO YOU. YOU WILL NEED TO FAX A COPY OF YOUR TICKET TO 850-872-8228 AND CALL MY OFFICE AT 850-913-9661 TO PROVIDE OTHER DETAILS NOT INCLUDED ON THIS FORM. DO NOT DELAY IN REQUESTING A HEARING OR CALLING MY OFFICE FOR ASSISTANCE IN REQUESTING A HEARING.
CALL OUR OFFICE IMMEDIATELY FOR
ASSISTANCE!
