EmailMe Form - Pre-DUI Evaluation Questions

Name *
First Last
Email *
Phone *
### - ### - ####
Zip Code *
Drivers License #
How many DUI arrests have you had? *
None
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