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Personal Information:

Name*: Address*: City*: State*: Please Select From List... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Phone Number: - - E-mail Address: Date of Birth: (mm/dd/yyyy) Month 01 02 03 04 05 06 07 08 09 10 11 12 / Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 /

Incident Information:

Date of Arrest*? County of Arrest*? Arresting Agency (which police department)*? What was the officer's reason for stopping you*? Were you involved in a traffic crash? (check if YES) If so, were you behind the wheel when the police arrived? (check if YES) Did the hospital draw blood from you? (check if YES) Did you admit to drinking/taking medication? (check if YES) Were you specific about amount of alcohol or drugs? (check if YES) Did the officer read you your rights? (check if YES) Did you do the roadside sobriety tests? (check if YES) Which ones? How do you think you did? Did you take a Breathalyzer test? (check if YES) What were the results?