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DWI Questionnaire 
 


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DWI Intake Information
Please fill out the form below to have an attorney evaluate your case. We will follow up with a FREE consultation regarding the facts of your case.

BACKGROUND INFORMATION *
Full Name
Address
Your Home Address
Telephone Number
E-mail Address *
Please Enter Your E-mail Address
PRIOR OFFENSES *
Do you have any Prior Alcohol related offenses (DWI or Careless Driving)
YES   
NO   
DON'T KNOW   
Explain
If your answer to the previous question was "yes" please provide the date, state, and county of the prior offense and explain the charge.
Representation
Were you represented by an attorney on your prior offense?
YES   
NO   
DON'T KNOW   
Enhancement
Did you know that a prior offense may enhance the current charges resulting mandatory jail time and/or greater fines?
YES   
NO   
CURRENT OFFENSE
Please provide the circumstances of teh current arrest. Please include in your response, the county or city in which you were arrested and the reason taht you were stopped if known.
Date *
Date of Arrest
Field Sobriety Tests
Were any of the Following Field Sobriety Tests performed after your arrest? (Check all that apply).
Nystagmus (Eye Test)   
PBT (Hand Held Breath Test)   
Walk and Turn   
Touch Nose   
One Leg Stand   
Alphabet   
Counting   
Other   
Submitting to Tests
Did you know that you are not required by law to submit to any field sobriety tests?
YES   
NO   
Alcohol Test *
Were you tested for Alcohol?
YES   
NO   
I REFUSED   
DON'T KNOW   
Test Refusal
If you refused to allow a test, were you informed that a refusal to test is a crime resulting in greater penalties in most cases than a test failure?
YES   
NO   
DON'T REMEMBER   
Test Performed *
If you were tested, what type of test was performed?
Breath   
Blood   
Urine   
Don't Know   
Attorney
Were you advised of your right to contact an attorney prior to being asked to submit to a test?
YES   
NO   
DON'T REMEMBER   
Test Result
If known, please indicate the Blood Alcohol Content of the test result and any other information that you feel is relevant?
Medications
Were you on any medications when you were arrested?
YES   
NO   
DON'T REMEMBER   
CONTACT ME *
Please indicate how you would like to be contacted?
Letter   
Phone   
E-mail   
I'll call you   

* Required to submit this form








About this Site  |  Ask-A-Lawyer: Questions  |  Business & Corporate Law  |  Minnesota Franchise Law  |  Freedom of Information Act  |  Criminal Defense Center  |  DWI Center  |  Minnesota Divorce  |  Collaborative Law  |  Estate Planning Center  |  Minnesota Juvenile Justice Center

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