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Duiintake

Eversole Law
2205 Morris Avenue
Birmingham, AL 35203
205-251-6666; 205-994-0616
fax: 205-323-3240
Instructions to Client: Please complete every part of this form to the best of your ability and be 100% truthful in every response. Your detailed answers to these questions will be of great value in assisting us in evaluating and defending your case. Lack of information greatly hinders our ability to discover all available defenses to attack the Government’s case against you. ALL DATA AND INFORMATION YOU SUBMIT ON THIS QUESTIONAIRRE WILL BE KEPT CONFIDENTIAL. We will not contact anyone you list on this form without your consent. ___________________________________________________________________________________________________________________________ Full Name:__________________________________________________________________________________________________________________ Birth Date: __/__/_____ Age:_______ Social Security Number (needed b/c many court records are keyed to this number) _________________________________________________________ Address:____________________________________________________________________________________________________________________ How long have you lived at the above address?____________________________________________ Phone Numbers: Work________________________Home:________________________Cell:______________________ Email address:___________________________________________________________________________________ Can you be contacted at work? Yes___________No__________________ Person to contact if you cannot be reached (include name, address, phone number) ___________________________________________________________________________________________________________________________ How were you referred to (or how did you hear about) our firm? _______________________________________________________________________ If referred, by whom?___________________________________________________________________ DRIVERS LICENSE INFORMATION
Driver’s License Number ______________________________ State Licensed in ___________________________ Restrictions to License? Yes No If so, what?_________________________________________________ CDL? Yes No If yes, what do you use it for?___________________________________________________ DL date of issue____/____/_____ Expiration ______/______/_____ EMPLOYMENT
Employer:__________________________________________________________________________________________________________________ Job Title:________________________________How long with current employer?____________________________________________ Annual Income: Under $25,000___$25,000-$50,000___Over $50,000___ Prior employment for last 5 years:_________________________________________________________________ Do you work with any type of paints or solvents? YES NO If yes, what type and for how long?________________________________________ Vehicle required for your current job? YES NO Would you be fired/demoted/restricted/or passed over for a promotion? a. if convicted of DUI?_____________________ b. if your DL is suspended or revoked?_________ Do you drive a company owned car? YES NO Do you lease your car? YES NO Does your company pay your car insurance? YES NO INFORMATION ON CAR DRIVING WHEN ARRESTED
Make: ______________Model:__________________Year:_____________ Your car? YES NO Had you driven the car before? YES NO Auto Stick Who owns the car if you do not?_______________________ Any know defects to the car? YES NO_______________________________________________________________________________________ PRIOR CRIMMINAL RECORD
(INCLUDE DATE OF ARREST, CHARGE, DISPOSITION of CHARGE AND SENTENCE RECEIVED) List all prior felony charges:____________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ List all prior misdemeanor charges: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ List all traffic violations (Other than DUI) for the last five years: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ List all prior convictions FOR DUI (include: date of conviction, location of conviction, sentence received (fine& jail days, etc) and whether or not you were represented by an attorney): _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ EFFECTS OF A POSSIBLE CONVICTION
What effect would a conviction have on you personally? _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ What effect would a conviction have on you professionally? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Describe your physical appearance when you were pulled over (state of your clothing; any stains on your clothes, hair, eyes, breath—chewing gum—smoking—chewing tobacco) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Did the cop make any comment about the interior of your car or your physical appearance? YES NO If so, what did he say? ________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ EVENTS OF THE DAY OF ARREST
During the 24 hour period prior to your arrest, describe your activities in GREAT DETAIL from the time you awoke until the time of your arrest. (List in chronological order) Tell us what you were doing, where you went, who was with you, what you ate, what you had to drink (alcoholic/nonalcoholic), what medications you took, etc. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Why do you feel you were pulled over? _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ What did the cop tell you was the reason that you were pulled over? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ What EXACTLY were the first words out of the cop’s mouth? _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Where was your license/tag registration? _____________________________________________________________________________________________________________ When and why did you first realize the cop was investigating you for a DUI? ________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________ Did the cop ever give you a Miranda Warning? (you have the right to remain silent, etc.)? YES NO If so, explain when: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Did you make any statements after you were informed of your Miranda Rights? YES NO If yes, what? _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Describe the interior of the car you were driving when pulled over (any open/unopened containers of alcohol, coolers, beer caps, wine glasses, mouth wash, etc) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ FIELD SOBRIETY TESTS
Did the cop command you to take an FST? YES NO If so, describe each test in individually and in detail (what instructions he gave you, where you were standing in relation to the police car, the condition of the surface you performed them on, the shoes you were wearing, lighting conditions, where you were in proximity to the road, how you felt you performed, etc) ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Did the cop ask you preliminary questions about your physical limitations or impairments or present illnesses before beginning the test? YES NO Describe the lighting of the area where you took the FST (were the cop car’s blue lights on? What was the moon like? Did the cop shine his light in your face? Which way were you facing in relation to the police car? Etc.) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Were you asked and did you blow into a hand-held breath machine on the roadside? YES NO If yes, if you could see the result, what was it?__________________________________________________________________________________ What type of shoes were you wearing?____________________________________________________________________________________________ What type of surface did you perform these “tests” on?________________________________________________________________________________ Were there any other people in the car with you when you were pulled over? YES NO______________________________________________________ If yes, who were they? (name, address, relationship, phone number-we wont contact anyone without your permission first): _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ What was their condition? (sober/drinking, impaired, etc)_____________________________________________________________________________ How did they get home?________________________________________________________________________________________________________ Were there any other witnesses? YES NO If so, who were they and what did they see? (name, address, phone number) _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Did anyone witness you drinking? If so, who?______________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ If you were drinking, how did you pay for your drinks? (cash, credit card, etc)______________________________________________________________________ List in GREAT DETAIL the events from when you got behind the wheel until the time you were pulled over (where were you coming from, where were you going, what was the traffic like, how many stop-signs or traffic lights did you go through, weather conditions, whether or not you had been drinking, where you had been drinking, what time it was, when did you first see the police car behind you, etc?). ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Do you know whether you were recorded by video or audio while at the police station? YES NO If yes, where were you recorded and what was the substance of the recordings?____________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________ Were you asked to submit any other type of chemical test? (urine, blood, saliva) YES NO If yes, what type, when did you take it, whom administered it, where did you take it? _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ACCIDENT
Complete only if you were involved in an accident
Describe the accident (how it occurred, road conditions, injuries, etc)______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Where were you when police arrived on the scene?_ ________________________________________________________________________________________________________________ Were you unconscious for any period of time? YES NO If yes, please describe_________________________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________ Did the airbags deploy? YES NO If yes, were you knocked out by them? YES NO How else did the airbags affect you? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ When did you first realize the cops were investigating you criminally instead of the accident? (why do you feel this way) ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ THE ARREST
Were you ever told you were “under arrest” or something similar? YES NO If so, when and by whom?______________________________________________________________________________________________________ Did the police officer search your vehicle? YES NO If so, when, and by whom, and what if anything was found/seized? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ AT THE JAIL
Were you requested to take a breath test? YES NO If yes, when, by whom, what was the substance of the request made? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Did you (cough, burp, sneeze, vomit, drink, smoke, eat, etc) between the time you were placed under arrest and the time you took the breath test? YES NO If yes, what and when in proximity to taking the test? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Were you told that you had the right to refuse the breath test? YES NO Did the police officer read you an Implied Consent statement? YES NO Did you request to make a phone call? YES NO If yes, when did you request, and when were you allowed to make one? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Did you ever request that an additional Blood Alcohol test be performed? YES NO If yes, when did you make this request, and what if anything did the cop(s) do? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ MEDICAL/PHYSICAL CONDITON AT TIME OF ARREST
Weight at time of arrest: ___________Height____________________ General health condtions:_______________________________________________________________________________________________________ Any physical disabilities/prior or recent surgery? (list all surgeries and injuries previously suffered)___________________________________________ ________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Any prescribed medication taken daily or periodically? YES NO If so, what?__________________________________________________________________________________________________________________ Any non-prescription medicine you take daily or periodically? YES NO If so, what?__________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ Specific health problems (asthma, GERD, heart disease, seizure disorder, etc)? _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Do you wear any dentures or dental work? YES NO If so, what?______________________________________________________________________ Do you wear glasses or contacts? YES NO If yes, were you wearing them when you were pulled over? YES NO_______________________________ Do you have an artificial eye? YES NO Do you have any other eye problems? _______________________________________________________ Do you have any piercings in your mouth? YES NO If so, what?_______________________________________________________________________ Do you have a speech impairment? YES NO If so, pleas describe______________________________________________________________________ How many hours had you worked the day you were arrested?___________________________________________________________________________ When had you last slept prior to your arrest, and for how long?_________________________________________________________________________ At the time of your arrest had you taken any of the following medications? If so, please elaborate. a. Prozac/Paxil/Zoloft/Luvox/Celexa/Cymbalta b. Adderall/Ritalin (amphetamines) c. Quinolone antibiotics d. Lariam e. Steriods f. Interferons g. Birth Control h. Other:____________________________________________________________ ___________________________________________________ OTHER LAWYERS
Prior to consulting with our law firm, have you consulted with any other lawyer? YES NO If yes, who?________________________________________________________________________________________________________________ Have you hired that lawyer/law firm? YES NO Are you aware that you are free to follow any other attorney’s advice and that you are not bound to hire me unless you choose to do so? YES NO Is there any other information that you feel I need to know about this incident that you have not previously mentioned? Is there any other information about you that you or your family feel will be either positive or negative in or our legal representation of you? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Source: http://www.criminal-defense-attorney.info/files/dui-intake.pdf

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