Drunk Driving Form

*Name:

Street Address:

City:

State:
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Zip:

Home Phone:

Okay to call you at this number?
Yes No

Work Phone:

Okay to call you at this number?
Yes No

Cell Phone:

Okay to call you at this number?
Yes No

*Email Address:

How did you find this website?

Date of Arrest:

Time of Arrest:

County of Arrest:

Did you take a breath test?

If so, what was the test result?

If not, did you refuse test?

Maryland Driver's License?
Yes No

If not, what State issued license?

Commercial Driver's License?
Yes No

Date of Birth:

Was license confiscated by police?
Yes No

Did you mail request for MVA Hearing?
Yes No

If so, date mailed:

Any prior drunk driving offenses?
Yes No

If so, state date, location, and results of each:

For this case, consulted with other attorneys?

Any appointments scheduled with other attorneys?

Name of Court:

Trial Date:

Trial Time:

Additional Comments: