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	About Your Case
	Have you ever been arrested before?
	Yes No
	Were you involved in an accident?
	Yes No
	What kind of chemical test did you take?
	Breath Urine Blood Not Applicable
	When is your next court date? (if available) What was the date of your arrest? (if available) What court are you scheduled to be in? (if available)
	Describe any special circumstances involved in your case
	Contact Information
	Mr .  Mrs.   Miss   Ms.   Dr.
	Name*
	If minor, check here
	Address
	City
	State   Zip
	Phone Number*   Mobile Telephone
	Best Time to Call Daytime Evening
	E-mail Address*

The transmission of information is not intended to and does not
create an attorney-client relationship.