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CRIMINAL DEFENSE INTAKE FORM (DWI)
Name: DOB/Age:
Phone #: Home Work Cell/Pager
Address - (STREET, CITY, STATE, ZIP CODE):
Court Appearance (Location) & Date:
Charges:
Prior Arrests/Prior DWIs:
Date of Arrest: Where:
Number of Drinks: Going to:
Reason for Stop & Brief Summary:
Accident/Injuries:
Breathalyzer Test: YES NO
Refused Result
Type of Driver’s License: State:
Employer:
Employer’s Address:
Position : License Needed For Work: Yes No
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