DUI/DWI INTAKE SHEET

First Name

Last Name

Street Address

Address Line 2

City

State

Zip Code

Phone Number

Email Address

Date of Birth

What is your Driver's License Number?

State in which License was Issued?

Do you have a CDL (Commercial Driver's License) ?

Yes

No

Did the Police take away your license?

Yes

No

Your Immigration status is

U.S. Citizen

Green Card Holder (LPR)

Other

Date of Ticket

What is (are) the ticket number (s)

What were you charged with?

Where did you Receive the Ticket?

What is your Court Date?

Has your Court Date Already Passed?

Yes

No

Indicates Response Required

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