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1. Did the officer take your driver's license or give you a paper called "Administrative Per Se Order of Suspension/Revocation, Temporary Driver License Endorsement"? Yes No
2. Have you contacted the DMV as requested on the Administrative Per Se Order?: Yes No If not, immediately call us at (805) 966-0812
3. If you have contacted the DMV within the 10 day limit, when is your appointment(date and time)?:
4. Have you ever been arrested for a DUI/DWI charge before? Yes No
5. What date were you arrested for the current offense?: (mm-dd-yyyy)
6. Approximately what time were you arrested?:
7. Approximately how many minutes went by from the time you were arrested (when they handcuffed you) until you arrived at the chemical test location (blood, breath or urine test location)?:
8. Approximately how many minutes went by from the time you arrived at the chemical test location until you took the first chemical test (blood, breath or urine test)?:
9. Did the officer have a valid reason for stopping or contacting you while you were in your vehicle?: Yes No I don't know/not applicable
10. What did the officer say was the reason for the traffic stop or contact with you (check any that apply)?: - Speeding - Weaving - Involved in accident - No injury to anyone - Involved in accident-Injuries to at least one person - Roadblock/Checkpoint - Unknown - I don't know - S/he didn't tell me
11. If none of the above apply, please indicate the reason for the stop of your vehicle or contact with you?:
12. Did the officer see you driving?: Yes No I don't know/not applicable
13. Did you admit to driving?: Yes No I don't know/not applicable
14. If you consumed alcoholic beverages, what type did you drink(s) (highlight all that apply)?: None consumed Beer-Regular Beer-Malt Liquor Beer-Bock Beer-Double Bock Wine Cooler Ale Champagne Wine Mixed Drinks Vodka Rum Gin Tequila Whiskey Scotch Bourbon Schnapps Cognac Alize Ripple Thunderbird Port Rubbing Alcohol Can't remember Other
15. If 'Other', please indicate type of beverage?:
16. Think about the drinks you had. Many people under estimate how many drinks they had, or cannot remember. However, this is extremely important to your case. In order to calculate your Blood Alcohol Level please indicate how many drinks you had total (one drink is equal to a 12 ounce beer, a regular glass of wine, or 1 shot (1 1/4 ounces of hard liquor)?: None consumed One (1 drink) Two (2 drinks) Three (3 drinks) Four (4 drinks) Five (5 drinks) Six (6 drinks) Seven (7 drinks) Eight (8 drinks) Nine (9 drinks) Ten (10 drinks) 11+ drinks Can't Remember Blacked Out
17. Approximately what time did you finish your LAST alcoholic beverage before you were pulled over?: I don't know/not applicable
18. What time did you tell the officer you last drank?:
19. If you were on prescription medications or other drugs, what type? (highlight all that apply)?: Not Applicable Anti-Depressant Pain Medication Valium/Tranquilizer Marijuana Methamphetamine Powder Cocaine Rock Cocaine Heroin 'Ecstasy' LSD Crystal Meth Peyote PCP Other
20. If 'Other', please indicate type of medication or drug?: I don't know/not applicable
21. What size meal did you have before the arrest?: Hadn't eaten within the time limit Bar Snacks Small meal Medium meal Large meal Extremely large meal
22. When, before the arrest, did you eat?:
24. Please select the field sobriety tests you were requested to perform? (check all that apply): - Did not take any field tests - Follow a pen, finger, or other object with you eyes, not moving your head - Standing with my head tilted back and eyes closed, feet together - Standing on one foot for a period of time and counting - Patting your hands together - Counting on your fingers - Saying or writing the ABC's - Walking a straight line, or heel-to-toe - Touching your nose with finger - Other
25. If 'Other', please indicate what they made you do?: I don't know/not applicable
26. Did you blow into a field breathalyzer or hand-held type gadget?: Yes No
27. If you know, what was the result of the hand-held breathalyzer gadget test?: I don't know/not applicable
28. Did the officer advise you that you could refuse to take the hand-held gadget breath test? Yes No I don't know/not applicable
29. Did you fail to satisfactorily perform the balance and coordination tests as demonstrated to you by the officer?: Yes No I don't know/not applicable
30. Please select the type of chemical test you took (or whether you took a chemical test at all): Blood Breath Urine No Chemical Test Taken I don't know/not applicable
31. What were the results of the test, if you know?: I don't know/not applicable
32. Did you take the chemical test (blood, breath or urine at the station or jail) within 1 1/2 hours after finishing your last drink?: Yes No I don't know/not applicable
33. If you are charged with refusing a chemical test - Which of the following apply? The cop told me I would have my license suspended if I refused a blood, breath or urine test, and I refused anyway. I refused during the initial vehicle stop or contact with the cop. I refused when they handcuffed me. I refused in the patrol car. I refused on the ride, in the patrol car, to the chemical test location. I refused at the chemical test location. I refused everything from the beginning. The cop told me I refused when he first stopped me. The cop told me I refused when we were doing Field Tests. The cop told me I refused when he handcuffed me. The cop told me I refused when we were in the car. The cop told me I refused when we were driving to the chemical test location. The cop told me I refused when we were at the chemical test location, but he didn't tell me I would lose my license if I refused. The cop told me I could refuse the test when he used a hand-held breathalyzer, so I did. The cop never told me I had to take a test and he didn't tell me I would loose my license for refusing. Other
34. If "other", please explain what happened:
35. After you arrived at the place where the breath machine was located, did you wait at least 15 minutes before your first breath into the machine?: Yes No I don't know/not applicable
36. If at least 15 minutes went by after arriving where the breath machine was located, what were you and the officer(s) doing during that period of time (highlight all that apply)? The officer(s) sat and watched me do nothing. The officer(s) were doing reports in my presence. The officer(s) were doing reports out of my presence The officer(s) were doing reports and talking with me and each other. I was sleeping. I was sick. I was vomiting. I was having indigestion. I was belching or burping. I was drinking. I was fighting with the cops I was getting my ass kicked by the cops Other
37. If 'Other', please indicate what happened?:
38. After the breath test was completed, did the officer advise you that you had the right to take a blood or urine test, in addition to the breath test, to insure the accuracy of the breath machine or so you could have a sample collected for future testing?: Yes No I don't know/not applicable
39. Did you take an additional blood or urine test? I did not give an additional sample. I wasn't sure if I should give an additional sample. I knew I was over the limit anyway. I can't remember. The officer(s) talked me out of doing it. The officer(s) told me it would be used against me also. The officer(s) didn't tell me about this right of mine. I gave a urine sample after the breath test. I gave a blood sample after the breath test. Other
40. For the urine test, did you completely empty your bladder the first time you urinated?: Yes No I don't know/not applicable
41. If no, why not?:
42. For the urine test, did the officer collect your urine the second time you urinated?: Yes No I don't know/not applicable
43. For the urine test, did an officer watch you closely or fail to respect your privacy when you provided the sample?: Yes No I don't know/not applicable
44. What type of law enforcement officer was the arresting officer (the one who gave you tests, handcuffed you, took you to jail)?: Sheriff City Police Officer Highway Patrol Undercover Narc Border Patrol Agent Airport Police Officer Federal Agent All I remember is that the fucker was huge Other Law Enforcement Officer
47. In which California Superior Court are you scheduled to appear?: -select one- (Alhambra) (Airport) (Beverly Hills) (Burbank) (Chatsworth) (Compton) (Culver City) (Downey) (East L.A.) (El Monte-Rio Hondo) (Fullerton) (Glendale) (Hollywood) (Huntington Park) (Inglewood) (Laguna Niguel) (Lancaster) (Long Beach) (Los Angeles-Bauchet St.) (Los Angeles-CCB) (Los Angeles-Metro) (Los Cerritos-Bellflower) (Lynwood) (Malibu) (Monrovia) (Newport Beach) (Norwalk) (Orange) (Pasadena) (Rio Hondo) (San Diego) (San Fernando) (San Pedro) (Santa Ana) (Santa Clarita) (Santa Monica) (South Gate) (Torrance) (Valencia) (Van Nuys) (Vista) (Westminster) (West Covina-Citrus) (Whittier)
48. In which Nevada Justice or Municipal Court are you scheduled to appear?: -select one- (Boulder City) (Carson City) (Goodsprings) (Henderson) (Las Vegas) (Las Vegas North) (Laughlin) (Mesquite) (Moapa Valley) (Pahrump) (Reno) (Tonopah) (other)
49. When is your court date?:
50. Have you consulted with another attorney since your arrest?: Yes No
51. Are you aware that a conviction and/or driver's license suspension for DUI/DWI will result in an insurance cancellation or a possible increase in cost between $15,000 to $25,000 during the next seven years?: Yes No
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