In what State(s) were you arrested?
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Did Your DUI arrest occur within the last 90 Days?
Yes No

Any Prior Alcohol Related Offenses?
Yes No

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Step 2 of 4

What alcohol test was performed?
Refused Blood Test Breath Test Urine Test Unsure
What was your blood alcohol content?
.00% -.04% .05% - .08% .09% - .12% .13% - .16% .17% - .20% > .20% Not Sure

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Step 3 of 4

Would you like to challenge the arrest?
Yes No
Do you need your license for any of the following?
School
Medical
Work
Family Needs

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Step 4 of 4

Name*

Email Address*

Phone Number*


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