Name

Address 1

Address 2

City

State

Zip Code

Best Phone #

Okay to call this number?

Alternate Phone #

Okay to call this number?

Email

Okay to email you at this address?

Search engine you used to find this website?

Search terms used

Date of Arrest

Time of Arrest

Day of the Week

City Where Arrested

Arresting Police Department

Court Date
(leave blank if unsure)

Court Appearance

Arraignment
PTC
Other

Moving violations cited for with the OUI arrest

Operating to Endanger/Reckless
Marked Lanes Violation
Speeding
Illegal U-Turn
RunningRed Light or Stop Sign
Defective Equipment
No Proof of Insurance
Unregistered
Failure to Yield
Other (Please specify below...)

Any other criminal charges?

Why did the police stop you?

Was there an accident?

Yes
No
Not Sure

Was anyone injured? (check all that apply):

No one was hurt
Myself
Passenger(s)in my vehicle
Passenger(s) in another vehicle
Pedestrian
Not Sure

Were you stopped at a police roadblock?

Yes
No

Did you perform field sobriety tests?

Yes
No
Don't recall
I Refused

Which field sobriety tests were you asked to perform? (Check all that apply)

Portable Breath Test
Walk and Turn
One-Leg Stand
Follow-the-Pen-With-Eyes
Say the Alphabet
Counting Backwards
Touch Your Nose
Other (Please list below...)

Please specify other tests you took, that are not listed above

Did officer advise you that you could refuse field tests?

Yes
No

Were you videotaped?

Yes
Roadside
Police Station
No
Not Sure

Did you take breath test?

Yes
No, I Refused
No, Test Was Not Offered to Me

Were you advised that an independent test could be done?

Yes
No

If yes above

Reading #1
Reading #2

Name of arresting officer

Name of breath testing officer

Street or location where arrested

Did you get an independent blood test?

Yes
No

If "yes", what was the result?

Did you ever ask to call an attorney?

Yes
No

If "yes", when (give details)?