STRUCKHOFF LAW OFFICE

PROSPECTIVE DWI/DUI CLIENT QUESTIONNAIRE
Please fill out this form and fax it to 603-448-2843 or 603-448-2957.

First Name: ____________________ M. I.: ___ Last Name: ____________________

Address 1: ____________________

Address 2: ____________________

City: ____________________ State: ____ ZIP Code: __________

Home Phone #: ____________________ May we call you at this number?   YES     NO

Work Phone #: ____________________ May we call you at this number?    YES    NO

Cell Phone #: ____________________    May we call you at this number?    YES    NO

Preferred phone # for call about initial consultation: ____________________

Best time to reach you at this #: ____________________

Pager#: ____________________

Fax#: ____________________ May we fax you at this number?    YES    NO

E-Mail address: ____________________ May we E-mail you at this address?    YES    NO

Date of Birth: ____________________

State in which you hold driver’s license: ____________________

Name of Court (on summons, complaint, or bail receipt): ____________________

Court Date (on summons, complaint, or bail receipt): ____________________

Date of Alleged DWI Offense: ____________________ Time of Alleged DWI Offense: ____________________

Location of Alleged DWI/DUI offense (Street or highway): ____________________

Name of Arresting Officer: ____________________

Police Department: ____________________

Why were you stopped, according to Officer?:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________

Were any other charges brought against you arising out of this incident
(Would be shown on your summons, complaint, or bail receipt.)    YES    NO    NOT SURE

Was there an accident?    YES    NO    NOT SURE

Did you perform roadside sobriety tests?     YES    NO    NOT SURE

Walk and turn (heel to toe)     YES    NO    NOT SURE

Stand on one leg     YES    NO    NOT SURE

Follow pen with eyes     YES    NO    NOT SURE

Say the alphabet     YES    NO    NOT SURE

Touch your finger to your nose     YES    NO    NOT SURE

Portable breath test machine     YES    NO    NOT SURE

Were you given a written or printed report of the result Readout %?     YES    NO    NOT SURE

Were you videotaped?     YES    NO    NOT SURE

By Camera on police cruiser     YES    NO    NOT SURE

By Camera at police station     YES    NO    NOT SURE

Did you take a breath test?     YES    NO    NOT SURE

Results shown on printout Subject #1 %: _______ Sample#2 %: _______

Reported value %: ________

WARNING: If you either refused a test or submitted to a test showing at or above the legal limit of .08% (.02%, if you are under 21, and .04%, if you were driving a commercial vehicle), you face an automatic suspension of your license or right to operate in New Hampshire for at least 180 days and for up to two years. Although you have a right to a hearing, a proper written request for such a hearing must be filed with the department of safety within 30 days. The rules for such filings are technical. Please call right away in order to preserve your right to such a hearing or if you have any questions about your rights or the legal limit that applies to you.

Did you take a blood test?     YES    NO    NOT SURE

Have you received blood test results?     YES    NO    NOT SURE

Result %: __________

Did you refuse to take a test?     YES    NO    NOT SURE

Were you given a temporary license?
(Pink 8 ½ x 11 form with six-digit number in upper right-hand corner and filled out by officer)     YES    NO    NOT SURE

If yes, date notice served (upper right-hand corner): ____________

If yes, name of law enforcement officer shown on bottom section of temporary license entitled,
"OFFICER’S REPORT.": ____________________

Have you gotten a CONFIRMATION OF A NOTICE OF SUSPENSION/ REVOCATION ACTION
from the NH Department of Safety?     YES    NO    NOT SURE

WARNING: If you have been previously convicted of dwi/dui within the last seven years in any state, you face a mandatory jail sentence in New Hampshire if convicted.

Is this your first DWI/DUI arrest?     YES    NO    NOT SURE

Have you ever been convicted of DWI or DUI?     YES    NO    NOT SURE

Please list any previous DWI convictions:

State: ___ Month: ______ Year: ______ Court: ____________________

State: ___ Month: ______ Year: ______ Court: ____________________

State: ___ Month: ______ Year: ______ Court: ____________________

State: ___ Month: ______ Year: ______ Court: ____________________

Have you ever lost your license for:

Refusal to submit to a chemical test?     YES    NO    NOT SURE

State: ___ Month: ______ Year: ______

Testing above the legal limit?     YES    NO    NOT SURE

State: ___ Month: ______ Year: ______

Kindly fax your temporary license, any complaints, summons, bail receipt, printout or letter reporting any chemical test result, and Motor Vehicle Department Notice to Struckhoff Law Office at 603-448-2843 or 448-2957.