In what City were you arrested?

Did you submit to a chemical test (breath or blood)?

Yes
No

-- If yes, please provide the BAC results (if you know them)?

Were you involved in an accident?

Yes
No

-- If yes, was anyone injured?

Yes
No

Do you have any prior DUI convictions?

Yes
No

-- If yes, where and in what year?

Have you contacted the DMV within 10 days from your arrest with regards to a hearing to save your license?

Yes
No

Please provide additional information pertinent to your case.

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