MARYLAND, DC AND VIRGINIA DWI FORM

If you are facing a drunk driving charge, you can receive a FREE consultation for your case. Just complete the form below and submit it to us, or you can call our office at 301 738-5700 or email this form 24 hours a day.

Please feel free to only complete as much information as you know or want to submit.

Please fill out the form below:

First Name Last Name

Address 1 Address 2

City State \par District of Columbia \par Maryland \par Hawaii \par Idaho \par Illinois \par Indiana \par Iowa \par Kansas \par Kentucky \par Louisiana \par Maine \par Georgia \par Massachusetts \par Michigan \par Minnesota \par Mississippi \par Missouri \par Montana \par Nebraska \par Nevada \par New Hampshire \par New Jersey \par New Mexico \par New York \par North Carolina \par North Dakota \par Ohio \par Oklahoma \par Oregon \par Pennsylvania \par Rhode Island \par South Carolina \par South Dakota \par Tennessee \par Texas \par Utah \par Vermont \par Virginia \par ZIP

Phone # Okay to call you at this number? Yes No

Alternate Phone# Okay to call you at this number? Yes No

Alternate number is a Pager Cellular Family Member/Friend Other

FAX Okay to fax you at this number? Yes No

Email Okay to email you at this address? Yes No

How did you find this web site? Alta Vista Maryland State website Attorney Find Excite Hotbot Infoseek Lycos Referred by someone Starting Point Webcrawler Microsoft Network Yahoo Other (Please specify below...)

Please specify how you found us, if not listed above

Are you mainly interested in fighting your DUI, or do you want to guilty?
Fight the case Plead Guilty Not Sure

Date of Arrest Time of Arrest

Day of the Week \par Sunday \par Monday \par Tuesday \par Wednesday \par Thursday \par Friday \par Saturday \par

State Where Arrested \par Maryland \par District of Columbia \par Virginia \par

Court Date (leave blank if unsure) Time of Court  

Name of Court

Driver's License # State Where Licensed \par Alabama \par Alaska \par Arizona \par Arkansas \par California \par Colorado \par Connecticut \par Delaware \par District of Columbia \par Florida \par Maryland \par Hawaii \par Idaho \par Illinois \par Indiana \par Iowa \par Kansas \par Kentucky \par Louisiana \par Maine \par Georgia \par Massachusetts \par Michigan \par Minnesota \par Mississippi \par Missouri \par Montana \par Nebraska \par Nevada \par New Hampshire \par New Jersey \par New Mexico \par New York \par North Carolina \par North Dakota \par Ohio \par Oklahoma \par Oregon \par Pennsylvania \par Rhode Island \par South Carolina \par South Dakota \par Tennessee \par Texas \par Utah \par Vermont \par Virginia \par Washington \par West Virginia \par Wisconsin \par Wyoming \par

Date of Birth

Is this your first DUI in your lifetime--anywhere, anytime? Yes No

If you have had prior DUI's please list them below:

Month/Year--------Court-------Result (Guilty, Not Guilty)

Are you currently on probation or parole? Yes No
If "yes", where?

Other Tickets/Charges received with this DUI (check all that apply):

• Failure to Maintain Lane
• Speeding
• Illegal U-Turn
• Running Red Light
• 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 Refused

Which field sobriety tests were you given? (Check all that apply)

• Handheld Breath Test
• Walk-and-turn 9 steps 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 you could refuse the test, but you could incur penalties as a result of your refusal? Yes No

Did you take breath test?

• Yes
• No, I Refused
• No, Test Was Not Offered to Me
• No, I Was Given a Blood Test
• Not Sure

WARNING: IF YOU REFUSED THE TEST OR WERE CHARGED WITH REFUSING THE TEST YOU FACE AN AUTOMATIC SUSPENSION OF YOUR LICENSE. GENERALLY, DEPENDING ON THE STATE, HAVE no more than 10  DAYS (5 DAYS IN D.C.) FROM THE DATE OF YOUR ARREST TO FILE A "REQUEST FOR HEARING" WITH THE APPROPRIATE GOVERNMENTAL AGENCY. READ YOUR FORMS CAREFULLY, THE DATES ARE IMPORTANT. CALL OUR OFFICE IMMEDIATELY 301 738-5700 AND ASK FOR STUART GROZBEAN FOR ASSISTANCE!

IF OVER THE WEEKEND EMAIL shgroz@bwg-law.com  You can also submit this form for quick response.

If you took a breath test you should have a print out of the two test samples. List your breath test results here. Sample #1 Sample #2

Blood test results Check here if test results are pending

Name of testing officer

Name of arresting officer

Name of police department

Street or location where stopped

County where stopped

Was your car towed? Yes No

Who called the tow truck? I Did Officer Did Not Sure

Who posted bond? I Did Bonding Company Family Member/Friend Other

Were there any witnesses with you who could testify for you? Yes No

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)?

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