OVI / DUI Intake Form Please enable JavaScript in your browser to complete this form.LayoutFull Name: *First and last name.SSN: *Social Security Number.DOB: *Date of birth.Address: *Client's address: street, city, state and zipcode.Email: *Phone: *LayoutDate/Time of Stop:DateTimeAgency:Law Enforcement Agency.Couny, City or Township.Location of Stop:Where did the stop occur.Drivers License Number:Client's driver's license number.Is this a CDL, commercial driver's license? *YesNoTraffic offense? *Why were you stopped?Were you involved in an accident: *YesNoAny injuries?YesNoLayoutDo you have any previous DUI / OVI convictions: *YesNoIf yes when and where did they occur?Date, City and State. How did the arrest occur?Provide a brief description of how the arrest occurred.Did you perform any field sobrity test? *YesNoChemical Tests:BreathBloodUrineIf you submited to a breath test what was the results?LayoutWas vehicle impounded? *YesNoIf yes where?Inpoundment location.LayoutCourt Hearing Location?Date / TimeDateTimeArraignment or Pre-TrialArraignmentPre-TrialLayoutAre you employed? *YesNoEmployer:Job Title:Does your employer require you to be able to drive during work? YesNoHow long does it take you to drive to work?LayoutDo you have to drive kids, spouse, parents?YesNoIf yes please explain?How did you find us?GoogleOther internet sourceReferralOtherSubmit
