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1

Have you been charged for operating under the influence?

2

Was your license suspended for a breath test refusal?

If you took the breath test what were the results:

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3

Did you take a field sobriety test?

Choose all that apply:

  • Recite Alphabet
  • Count Backwards
  • 1 Leg Stand
  • Heel to Toe Walk
  • Horizontal Gaze
  • Finger to Nose

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4

Do you have prior OUI offenses?

How many:

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5

Were you in an accident?

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6

Were you stopped (pulled over) by the police but not in an accident?

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7

Was any alcohol found in your vehicle?

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8

Did you tell the police that you consumed alcohol:

How many drinks:

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9

Did you receive a citation at the time of your arrest?

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Thank you for completing this form. We will be contacting you shortly about your case.
* All Fields Required.


  • Eg: 781-555-1212