Contact Chestney-Hawkins

This is a confidential form so we may know more about your case, and determine how we can best assist you.  The information you send is completely encrypted and protected from any other viewer.

This form is comprehensive and will take a few minutes to complete.  By doing so, you will allow us to access your situation and have some valuable information ready when we contact you.

If you prefer not to fill out this form, but would rather call us directly, please be prepared to give us the following information over the telephone. 

Contact Information
Title:
Name:
Work Phone: 
Home Phone:
E-mail Address:
State:
Incident Information
Would a DUI conviction or license suspension affect your job? 
Please list the exact time and date of your arrest: 
Please list the city, county, and/or police agency associated with your arrest:

What reason did the officer tell you he/she had for stopping you?
Select any of the following Field Sobriety Tests that you were given:
Alphabet

Any special instructions? 
Horizontal Gaze Nystagmus (follow pen/finger with eyes)

One leg stand
For how many seconds? Both legs? 
9-Step Walk - Turn (heel-to-toe)
Finger to nose
Counting

Alco-Sensor (portable breath test)

Results of Alco-Sensor test:
Were any of these tests, or any part of the arrest, recorded on video? 
What were your breath test results (not the portable Alco-Sensor)? 
And the time of the test? 
Where you given a blood test? 
Where was the blood test administered? 

At any time, did you request a test of your own (Blood, Urine, Breath)? 

Please explain your request:
Did you get one?  
Have you ever had any prior DUI's? 
If yes how many? 
Additional Comments

Do you have any other brief comments about your case we should know about before we speak with you?
 
 
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