Free Online Case Evaluation

We welcome the chance to meet with you for a free consultation to discuss the charges against you and how to best protect your rights and record.

Need More Information? Fill out and submit the following form (* - Required Fields). One of our attorneys will respond within 24 hours. If this form is too long for you, please fill out this form instead. You can also Contact Ed Loss at: 623-931-6362.

* First Name:		* Last Name:
Address 1:		Address 2:
City:		State:
Zip:		* E-Mail:
* Phone Number:		Fax Number:
Okay to call you at this number?		Yes No
Alternate Phone:		Alternate number is a:
Okay to call you at this number?		Yes No
Are you mainly interested in fighting your DUI, or do you want to plead nolo or guilty?
Date of Arrest:		Time of Arrest:
Day of the Week:		State Where Arrested:
City Where Arrested:		County Where Arrested:
Is this your first DUI/DWI in your lifetime--anywhere, anytime?		Yes No
If "yes", where?
If "yes", for what offense(s)?
Other Tickets/Charges received with this DUI (check all that apply):		Failure to Maintain Lane Speeding Illegal U-Turn Running Red Light/Stop Sign Defective Equipment No Proof of Insurance Failure to Yield Other (Please specify below...)
Please specify other charges ( not listed above)		Why were you stopped/arrested, according to officer?
Was there an accident?		Yes No Not Sure
Was anyone injured? (check all that apply):		No one was hurt/Not applicable Myself Passenger(s) in my vehicle Passenger(s) in another vehicle Pedestrian Not Sure
Were you stopped at a roadblock?		Yes No
Were you given field sobriety tests at the location where you were stopped?		Yes No Don't recall I Refused
Which field sobriety tests were you given? (Check all that apply)		Hand held Breath Test Walking heel to toe One-Leg Stand Follow-the-Pen-With-Eyes Say the Alphabet Touch Your Nose Other (Please specify below...)
Please specify other tests you took, that are not listed above:
Did officer advise you that field tests were 100% optional and that no penalty would result from not doing them?		Yes No
Were you videotaped at any point during your arrest?		Yes No Not Sure
Did you take breath test?		Yes No, I Refused No, Test Was Not Offered to Me No, I Was Given a Blood Test I was given all three test-- blood, breath and urine Not Sure
WARNING: IF YOU REFUSED THE TEST, OR WERE ACCUSED OF REFUSING THE TEST, YOU FACE AN AUTOMATIC SUSPENSION OF YOUR LICENSE FOR ONE OR MORE YEARS. YOU HAVE 15 BUSINESS DAYS FROM THE DATE OF YOUR ARREST TO REQUEST AN ADMINISTRATIVE HEARING WHICH OUR OFFICE FILES FOR ALL NEW CLIENTS AS PART OF OUR ROUTINE INTAKE PROCEDURE. IF YOU SUBMITTED TO A TEST WHICH PURPORTS AN ALCOHOL CONCENTRATION OF 0.08 GRAMS OR GREATER (.04 GRAMS IN A COMMERCIAL VEHICLE), YOU MAY SUSPENDED FOR NO LESS THAN 90 DAYS. PERSON UNDER 21 WITH ANY ALCOHOL IN THEIR SYSTEM STAND TO LOSE THEIR DRIVING PRIVILEGES FOR TWO YEARS. CALL OUR OFFICE IMMEDIATELY FOR ASSISTANCE! 623-931-6362
If you took a breath test you should POSSESS a print-out of the two test samples. List your breath test results here:		Sample #1 Sample #2
Amount of bond?
At any time during your arrest did you ever ask for or inquire about getting your own independent blood, breath or urine test?		Yes No
Did you get an independent blood, breath or urine test?		Yes No
If "yes", what was the result?
Check here if test results are pending
Did you ever ask to call an attorney?		Yes No
If "yes", when (give details)?
Additional Comments Are Welcome:

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DISCLAIMER: The foregoing is not to be construed as legal advice to or for any specific individual. Always seek the advice of counsel for specific legal problems.

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America 's Top DUI & DWI Defense Attorneys

Free Online Case Evaluation

CALL OUR OFFICE IMMEDIATELY FOR ASSISTANCE! 623-931-6362

CALL OUR OFFICE IMMEDIATELY FOR ASSISTANCE!
623-931-6362