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 tests performed?

Breathalizer
Blood
Walk and Turn
One leg stand
Check your eyes
Refused Test

If blood or breath test given what were the results:

Please describe your situation:

Were you arrested at the scene?

Yes
No

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