First Name:* MI:Last Name:*

Street Address:*

City* ST* Zip*

Primary Phone:* ( ) -

Cell Phone: ( ) -

Email Address:*

Do you have an office appointment? Yes No

If, no, what day is best for an office appointment? Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Do you prefer a morning or afternoon appointment? Morning Afternoon

Do you have a commercial drivers license?* No Yes

Date of Birth:* January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ,

Driver’s License #

License issued by which State: 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

Date of Arrest:* January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ,

In which parish were you arrested? Allen Beauregard Calcasieu Cameron Jefferson Davis Other Not Sure

Who was the arresting authority? Lake Charles Police Department Louisiana State Police Calcasieu Parish Sheriff's Office Sulphur Police Department Westlake Police Department Other

If "Other" was selected, please list the arresting authority:

Was your arrest the result of a DWI checkpoint? Yes No

Did you submit to field sobriety test? Yes No

Did you submit to the intoxilyzer device? Yes No

If yes, what was the reading?

Did the authorities obtain a urine sample? Yes No

Did the authorities obtain a blood sample? Yes No

Were you taking any prescription medication at the time of arrest? Yes No

If "Yes" was selected, please list the medications:

Please list all other violations accompanying the DWI arrest:

Have you been to court for your arraignment? Yes No

If "Yes", what is your trial date? Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ,

What type of vehicle were you operating? Motor Vehicle Watercraft Other

Year of Car Make Model

Were you the registered owner of the vehicle? Yes No

Did this arrest involve a motor vehicle accident? Yes No

If "Yes", do you have car insurance? Yes No

How many vehicles were involved? 0 1 2 3 4 5 6 7 8 9 10 over 10

Was anyone injured? Yes No Were any fatalities involved? Yes No

If "Yes" was selected to either question above, provide a description:

Were you transported to the hospital? Yes No

Was anyone else transported to the hospital? Yes No Not Sure

Please provide any other relevant details that might be helpful to your defense.

Does your employment involve driving a vehicle? Yes No

Will a conviction of a DWI cost you your job? Yes No

Have you been convicted or plead guilty to DWI offenses in the last 10 years?

Yes No If yes, how many? 0 1 2 3 4 5 6 7 8 9 10 over 10

Have you ever been guilty or plead to a reckless operation of a motor vehicle?

Yes No If yes, how many? 0 1 2 3 4 5 6 7 8 9 10 over 10 What kind? Motor Vehicle Watercraft Other

Have you plead guilty or been convicted of any prior drug offenses? Yes No

If "Yes", please explain in detail:

Are you currently on parole? Yes No

Are you currently on probation? Yes No

If yes, is your probation supervised or unsupervised? Supervised Unsupervised Not Applicable

If you answered yes to either question above, provide details in box below: