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First Name
 
Last Name
 
Phone
 
Email
 
Age
 
Arrest Date
 
What city were you arrested in?
 
Did you submit to a breathalyzer test?
 
If YES, what was your blood alcohol content (BAC)?
 
Did you submit to road side sobriety tests?
 
Did you admit to using alcohol or drugs?
 
Do you have any prior alcohol or drug related offenses in the past 6 years?
 
If YES, how many?
 
 
 
Questions?
         
   


   

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