Title
DR
MISS
MR
MRS
MS
First Name *
Last Name *
Email Address *
Contact Phone Number *
Home Phone Number
Referred by:
Home Address
City
State
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Country
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AFGHANISTAN
ALAND ISLANDS
ALBANIA
ALGERIA
AMERICAN SAMOA
ANDORRA
ANGOLA
ANGUILLA
ANTARCTICA
ANTIGUA AND BARBUDA
ARGENTINA
ARMENIA
ARUBA
AUSTRALIA
AUSTRIA
AZERBAIJAN
BAHAMAS
BAHRAIN
BANGLADESH
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BELARUS
BELGIUM
BELIZE
BENIN
BERMUDA
BHUTAN
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BOTSWANA
BOUVET ISLAND
BRAZIL
BRITISH INDIAN OCEAN TERRITORY
BRUNEI DARUSSALAM
BULGARIA
BURKINA FASO
BURUNDI
CAMBODIA
CAMEROON
CANADA
CAPE VERDE
CâTE D'IVOIRE
CAYMAN ISLANDS
CENTRAL AFRICAN REPUBLIC
CHAD
CHILE
CHINA
CHRISTMAS ISLAND
COCOS (KEELING) ISLANDS
COLOMBIA
COMOROS
CONGO
CONGO, THE DEMOCRATIC REPUBLIC OF THE
COOK ISLANDS
COSTA RICA
CROATIA
CUBA
CYPRUS
CZECH REPUBLIC
DENMARK
DJIBOUTI
DOMINICA
DOMINICAN REPUBLIC
ECUADOR
EGYPT
EL SALVADOR
EQUATORIAL GUINEA
ERITREA
ESTONIA
ETHIOPIA
FALKLAND ISLANDS (MALVINAS)
FAROE ISLANDS
FIJI
FINLAND
FRANCE
FRENCH GUIANA
FRENCH POLYNESIA
FRENCH SOUTHERN TERRITORIES
GABON
GAMBIA
GEORGIA
GERMANY
GHANA
GIBRALTAR
GREECE
GREENLAND
GRENADA
GUADELOUPE
GUAM
GUATEMALA
GUINEA
GUINEA-BISSAU
GUYANA
HAITI
HEARD ISLAND AND MCDONALD ISLANDS
HOLY SEE (VATICAN CITY STATE)
HONDURAS
HONG KONG
HUNGARY
ICELAND
INDIA
INDONESIA
IRAN, ISLAMIC REPUBLIC OF
IRAQ
IRELAND
ISRAEL
ITALY
JAMAICA
JAPAN
JORDAN
KAZAKHSTAN
KENYA
KIRIBATI
KOREA, DEMOCRATIC PEOPLE'S REPUBLIC OF
KOREA, REPUBLIC OF
KUWAIT
KYRGYZSTAN
LAO PEOPLE'S DEMOCRATIC REPUBLIC
LATVIA
LEBANON
LESOTHO
LIBERIA
LIBYAN ARAB JAMAHIRIYA
LIECHTENSTEIN
LITHUANIA
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MADAGASCAR
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MALDIVES
MALI
MALTA
MARSHALL ISLANDS
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MAYOTTE
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MICRONESIA, FEDERATED STATES OF
MOLDOVA, REPUBLIC OF
MONACO
MONGOLIA
MONTSERRAT
MOROCCO
MOZAMBIQUE
MYANMAR
NAMIBIA
NAURU
NEPAL
NETHERLANDS
NETHERLANDS ANTILLES
NEW CALEDONIA
NEW ZEALAND
NICARAGUA
NIGER
NIGERIA
NIUE
NORFOLK ISLAND
NORTHERN MARIANA ISLANDS
NORWAY
OMAN
PAKISTAN
PALAU
PALESTINIAN TERRITORY, OCCUPIED
PANAMA
PAPUA NEW GUINEA
PARAGUAY
PERU
PHILIPPINES
PITCAIRN
POLAND
PORTUGAL
PUERTO RICO
QATAR
REUNION
ROMANIA
RUSSIAN FEDERATION
RWANDA
SAINT HELENA
SAINT KITTS AND NEVIS
SAINT LUCIA
SAINT PIERRE AND MIQUELON
SAINT VINCENT AND THE GRENADINES
SAMOA
SAN MARINO
SAO TOME AND PRINCIPE
SAUDI ARABIA
SENEGAL
SERBIA AND MONTENEGRO
SEYCHELLES
SIERRA LEONE
SINGAPORE
SLOVAKIA
SLOVENIA
SOLOMON ISLANDS
SOMALIA
SOUTH AFRICA
SOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDS
SPAIN
SRI LANKA
SUDAN
SURINAME
SVALBARD AND JAN MAYEN
SWAZILAND
SWEDEN
SWITZERLAND
SYRIAN ARAB REPUBLIC
TAIWAN
TAJIKISTAN
TANZANIA, UNITED REPUBLIC OF
THAILAND
TIMOR-LESTE
TOGO
TOKELAU
TONGA
TRINIDAD AND TOBAGO
TUNISIA
TURKEY
TURKMENISTAN
TURKS AND CAICOS ISLANDS
TUVALU
UGANDA
UKRAINE
UNITED ARAB EMIRATES
UNITED KINGDOM
UNITED STATES
UNITED STATES MINOR OUTLYING ISLANDS
URUGUAY
UZBEKISTAN
VANUATU
VENEZUELA
VIETNAM
VIRGIN ISLANDS, BRITISH
VIRGIN ISLANDS, U.S.
WALLIS AND FUTUNA
WESTERN SAHARA
YEMEN
ZAMBIA
ZIMBABWE
Employer
Employer Address
Licenses you hold:
CDL?
Yes
No
Pilot License?
Yes
No
Professional License
Yes
No
Type of Profession
Your Georgia DUI Case
State of Stop
-- Please select --
Georgia
Florida
Alabama
Date of Stop
County of Stop
Police Agency
Was there an accident involved?
-- Please select --
Yes
No
I don't know
Why were you stopped?
Police officer's first comments:
Did Police ask you how much you had to drink?
-- Please select --
Yes
No
I don't know
What did you tell the Officer?
What and how much did you drink/smoke/other?
Were field test performed?
-- Please select --
Yes
No
I don't know
Were you informed that they are voluntary?
-- Please select --
Yes
No
I don't know
Were Miranda rights read to you?
-- Please select --
Yes
No
I don't know
Which field tests were administered?
HGN-Eye
One Leg Stand
Count to 30
Walk and Turn
Finger to Nose
ABC's
Five Finger Dexterity
Portable Breath Test
What were the results of the breath test?
At what point were you arrested?
Was the following read to you?
-- Please select --
Yes
No
I don't know
Did you blow into the Intoxilyzer 9000?
-- Please select --
Yes
No
I don't know
Did you refuse the test?
-- Please select --
Yes
No
I don't know
Did you request an explanation?
-- Please select --
Yes
No
I don't know
Did you ask for an independent test?
-- Please select --
Yes
No
I don't know
Reason given for refusal:
How was blood taken?
How was blood sent to lab?
Location of Court
Do you need a Ten Day Letter?
Yes
No
I Don't Know
Submit