DUI Questionnaire

If you have been charged with Driving Under the Influence in Pennsylvania, please fill out the following confidential questionnaire and submit it to us. Or you can call at (610) 432-7040 for a FREE consultation.

NOTE: By submitting the following information, no lawyer-client relationship is created. This office can only represent you when we have discussed your case in person or by phone, when acceptable fee arrangements have been made, and when you sign the appropriate authorizations for us to get needed information.

However, until your lawyers get the necessary information, they cannot begin to help you. Under the Pennsylvania DUI statute, time may be of the essence in protecting your license, so do not delay in seeking counsel, no matter who you ultimately select to represent you.


Name:
City:	State: Pennsylvania
Where do you work?
What do you do?
Phone Number where you can be reached during the day:
Other Phone:
May we contact you at this number? Yes No
Email:
Do you primarily want to fight your DUI, or are you most interested in working out the best deal that you can? Fight the case Plead Nolo Plead Guilty Not Sure
Date of Arrest:
Time of Arrest:
State Where Arrested:
Court Date (if known):
Time of Court:
Name and Location of Court :
Driver's License #:
State Where Licensed:
Date of Birth:
Have you ever previously been charged with DUI or any other criminal offense? Yes No Please list all previous criminal convictions: Month/Year --------Court-------Result (Guilty, Not Guilty, Nolo) Are you currently on probation or parole for any offense? Yes No If "yes", what is the name of the court, and what was the offense you were convicted of? Other Tickets/Charges received with this DUI (check all that apply): Failure to Maintain Lane Speeding # of Swerves over yellow line # of Swerves over fog line Illegal Turn Red Light Violation Defective Equipment No Proof of Insurance Failure to Yield Other Why were you stopped/arrested, according to the arresting officer?
What kind of vehicle were you driving?
Was there any other vehicle involved in your arrest? (such as an accident or a near miss?) Did you have any conversation with any other driver or witness? (Identify them, if you know them) Was anyone injured? (check all that apply): No one was hurt/Not applicable Myself Passenger(s) in my vehicle Passenger(s) in another vehicle Pedestrian Not Sure If you know, describe the nature of the injuries, if any: Were you stopped at a roadblock? Yes No
Name of arresting officer:
Name of police department/sheriff's office:
Street or location where stopped:
County where stopped:
Was your car towed? Yes No Who called the tow truck? I did Officer did Not Sure Were you given field sobriety tests at the location where you were stopped? Yes No Don't Recall Refused Which field sobriety tests were you given? (Check all that apply) Handheld Breath Test Walk-and-turn One-Leg Stand Say the Alphabet Gaze Nystagmus (pen or flashlight moved back and forth in front of you) Touch Your Nose Pick up Coins Other Did you take breath test? Yes No, I refused No test offered Not sure WARNING: IF YOU WERE CHARGED WITH REFUSING THE TEST YOU MAY FACE AN AUTOMATIC SUSPENSION OF YOUR LICENSE FOR ONE OR MORE YEARS. YOU HAVE 30 DAYS FROM THE DATE OF THE RECEIPT OF THE NOTICE OF SUSPENSION FROM THE PA. DEPT. OF TRANSPORTATION TO FILE AN APPEAL AND "REQUEST FOR HEARING" WITH THE DEPARTMENT OF TRANSPORTATION. CALL AN ATTORNEY IMMEDIATELY FOR ASSISTANCE! If the police have informed you of your breath test results, please state what the alcohol levels were here. Sample 1: Sample 2: Blood test results: (If blood test results are not complete, please enter "pending") Did you read and sign the consent? Yes No Not Sure Name of testing officer: Were there any witnesses with you who could testify for you? Yes No If so, please give names and phone numbers: At any time during your arrest did you ever ask for or inquire about getting your own independent blood, breath or urine test? Yes No Did you get an independent blood, breath or urine test? Yes No If "yes", what was the result? Did you ever ask to call an attorney? Yes No If "yes", when (give details)? Who were you with in the three hours before you were stopped? (Include phone numbers) How were you feeling at the time you were stopped? Any upset stomach? Migraine headache? Cold? Flu? What did you have to eat in the eight hours before you were stopped? Had you worked on the day you were stopped? If so, how many hours? Had you been awake for an unusually long time at the time of your arrest? Do you have any medical condition which might affect your balance or ability to perform field sobriety tests? Were you taking any of the following on the day of your arrest? Cold Pills Tranquilizers Weight control pills Do you have any of the following? Dentures or dental bridgework Diabetes Deafness or hearing impediment Speech impediment Is there anything else that you think we should know?