DUI/DWI/OUI Biographical InformationName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Driver's License State and NumberAre you a United States citizen?*YesNoDo you hold a Commercial Driver's License (CDL)?NoYesDo you hold any professional license (fly, teach etc.)?NoYesList all prior criminal incidents, charges, investigations, arrests or convictions. Include court, date & outcomeCurrent ChargesList all new charges & the date they were incurredCourt date & locationReason for initial stopDid you admit to consuming alcohol or drugs?NoYesDid you submit to field sobriety tests (watching pen/light, walking in line, standing on one leg)?NoYesWere you asked to say the alphabet, count, perform any other tests?NoYesDid you take a Preliminary Breath Test (PBT) by your car?NoYesDo you have any diagnosed medical problems with your back, legs or balance?NoYesDid you take a chemical test (breath, blood or urine)?NoYesErker Law Firm Online Form Disclaimer* I agree I agree and understand that I am voluntarily providing information about my legal issue to solicit contact from the Erker Law Firm. I further agree and understand that my voluntary submission of information is not required, is made in my sole discretion, does not create an attorney-client relationship, and does not constitute legal advice. I further agree and understand that submission of information does not guarantee that any member of the Erker Law Firm will respond to my submission or take any legal action on my behalf. I further acknowledge and understand that the submission of any material or information via this website utilizes e-mail which, is not a secured method of communication, may be copied and held by various computers it passes through as it goes from me to the firm or vice versa, and which may be intercepted by persons not participating in my communication by improperly accessing my or the Erker Law Firm’s computers or some computer unconnected to either of us which the e-mail passes through. I also acknowledge that my submission via this website constitutes my express consent to receive return communication via e-mail.EmailThis field is for validation purposes and should be left unchanged.