Do you have any previous drunk driving convictions?

Yes
No

If yes how many?

Select 1 2 more than 2

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

eg. xxx-xxx-xxxx

* Please explain your legal situation.

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