What is your current street address:

City State Zip Code

Ohio Driver's License Number

Date of Birth Date of Incident

Is this your first Offense? Yes No

If No, Please give the dates of prior convictions, and which courts:

Was there a breath/blood test administered? Yes No

If yes, which one? Breath Blood Urine

What was the reading?

Were any other tickets issued with with the DUI citation? Yes No

If yes, what were they?

Was there an accident involved? Yes No

If yes, who was cited?

What was the time of the arrest?

City where arrested?

County where arrested?

Name of Court?

Court Date:

Do you have a prior driving record? Yes No

Are there any prior DUI's? Yes No

If there are prior DUI's, please list them:

Did you have a valid Ohio Drivers License at the time? Yes No

Did you have automobile insurance at the time? Yes No

Are you currently on probation or parole? Yes No

What is the Best Phone number to reach you?

As soon as I receive your case information I will call you. Therefore, you must provide a phone number where I can reach you.