QUESTIONNAIRE

dui questions gwinnett attorney law firmFill out the questionnaire to the best of your recollection.  Submit to us.  All information will be kept confidential. Someone from our office will contact you to set up an interview and we will evaluate your case.  All of this is FREE.

You can also call our office at (678) 690-5190.

WARNING:    If you are accused of refusing to take the State test after being arrested for DUI, if your test results were above the legal limit, or if you were served with a DDS 1205 Notice- 30 Day Driving Permit, your license is at risk of being suspended. You only have 10 business days to request an Administrative Hearing or risk losing your driving privileges in Georgia. Call our office immediately to get more information about saving your driver’s license.

Your Name (required)

Street Address

City

State

Zip Code

County

Email Address (required)

Phone Number

May We Contact You At This Number?
YesNo

Work Phone

May We Contact You At This Number?
YesNo

How did you find us?

Date of Arrest (required)

Time of Arrest (required) (hh/mm/ss) (am or pm)

Court Date (required)

Court Time (required) (hh/mm/ss) (am or pm)

Name of Court (required)

Drivers License Number (required)

State Where Licensed (required)

Date of Birth (required)

Is this your first DUI/DWI lifetime - anywhere, anytime?
YesNo

If you had prior DUIs - List below. (Month/Year - Court - (Guilty, Nolo, Not Guilty)

Are you currently on probation or parole?
YesNo

If yes, where and for what?

Name of Arresting Officer

Name of Police Department

Why were you stopped according to the officer?

Other charges received with this DUI (check all that apply)
Failure to maintain laneSpeedingFailure to yieldIllegal U-turnRunning red light / stop signOther

Please specify other charges not listed above

Was there an accident?
YesNo

Was anyone injured?
YesNo

Were you stopped at a roadblock?
YesNo

Which field sobriety tests were you given? (check all that apply) (required)
NoneHand held breath testFollow the pen with eyesTouch your noseWalk heel to toeOne-leg standSay the alphabet

Did you take a breath test?
YesNo, I refusedNo, It was not offeredUrine TestBlood Test

If you took the breath test, you should possess a printout of the two samples

Same One

Sample Two

Street or Location where stopped

Was your car towed?
YesNo

Who posted bond?
I didBonding companyA FriendA Family Member

How long were you in custody?

At any time did you ask for your own independent blood, breath, or urine test?
YesNo

Please explain your request and results

Additional brief comments