EmailMeForm
Pre-Evaluation Questions
Name
*
First
Last
Email
*
Phone
*
###
-
###
-
####
Zip Code
*
Drivers License #
How many DUI arrests have you had?
One
Two
Three or More
Out of State DUI, DWI, OWI Arrests?
Yes
No
Date of Last Arrest
MM
/
DD
/
YYYY
Have you had a Hearing and been denied?
*
I Never been to hearing.
I have been to a hearing and denied.
Other
Did you participate in any Counseling or Education after most recent arrest?
No I have not.
Yes I have.
Employment Status
Full time
Part time
Unemployed or Student
Job Description
Available Documents
Yes
No
Drivers Abstract
Sworn Reports
Evaluations
Orders of Denial
Treatment / Education
Comments
