PERSONAL INFORMATION   *Name: *Address 1: Address 2: *City: *County: *Zipcode: *Telephone Number: ACCUSATION DETAILS   What are you accused of: Select DUI/OV DUS Traffic Offense Criminal Offense Other I was given the following tests to determine if I was intoxicated:  Field sobriety tests (walking a straight line, balancing, reciting the alphabet, etc.)  Blood, breath or urine sample at the police station The test showed my blood alcohol level was: The Number of previous times you have been convicted or pled guilty to drunk driving / DWI / DUI: ARREST DETAILS   Date of arrest / citation: (MM-DD-YYYY) Date of next court appearance: (MM-DD-YYYY) Where were you charged: I know the names and locations of witnesses to the arrest: Yes   No   Not Applicable PERSONAL DETAILS   Are you currently on probation: Yes   No Sex: Male   Female Age: Citizenship or Residency Status: US Citizen   Resident Alien   Other