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State: Number:

If yes, what branch:

If yes, how many miles do you travel per year for your employer?

If yes, when?

If yes, give details:

If yes, what was your answer?

If so, please give the number of passengers and the names of each passenger:

If yes, how?

If so, please indicate the name of the medication and dosage taken at the time of the arrest:

If so, please indicate:

If yes, what type of medication do you take for treatment of this disease:

If yes, please indicate:

If yes, please indicate what kind of medication you take, if any:

If so, please state the type of corrective lense that you wear:

If so, please describe:

If yes, please indicate the dates and locations of prior DUI arrests or convictions:

If yes, please state the nature of your problem:

If yes, please advise what type of counseling you would like to have:

If yes, please give the nature of the charge and the dates of the offenses:

If so, please list all person(s) with a complete address, phone and relationship: I grant you permission to talk with the above named parties regarding my case.

  Contact Guy Sharpe for a Free Consultation, (770) 590-9090.