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* Are you willing to pay at least $4,000 for retention of legal services?

Yes

Do you have any previous drunk driving convictions?

Yes
No

If yes how many?

Were you involved in an accident?

Yes
No

If yes was anyone hurt?

Yes
No

Were any of the following field sobriety tests performed (check all that apply)?

Breathalizer
Alphabet
Counting
Balance
Nose

Please describe your situation:

Were you arrested at the scene?

Yes
No

* What is the best method for the attorney to conact you?

Telephone
E-mail

If by telephone, what is the best time for the attorney to contact you?


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