Questionnaire
Complete this form on-line or print it for later use. FAX or mail completed form to:Advocate Legal Services at 2100 Goodyear #11, Ventura, CA 93001FAX to: (805) 650-4968
Were you eating while drinking? if yes, what food?
Yes
No
Please give nearest intersection or street names / addresses for the next two questions
If you paid for your drinks with a credit card, supply copy of receipt with this form.
What is the time & distance from the place where you completed your last drink to the place of the stop?
If different from actual, why did you tell officer other than truth?
How much time elapsed from the time of completion of your last drink to the time you left?
PM
AM
What was the time you completed your last drink?
With this in mind, provide the type of drink and the time the drink started:
(*State the size of the drink (number of ounces), the type (Bud, Coors etc. Scotch & water etc.) If any of the drinks were double size please indicate.)
Drink#:
Time:
Did you use a hand held breath detector to check your possible BAC prior to driving? If yes what was the reading?
If you consumed any drugs or medicine, including non-prescription medicine, like cough medicine, which contains alcohol the day of your arrest state the type of drug and the time you took each drug:
If you blew into a hand-held breath device, what were results--If known:
What type of chemical test did you take after you were arrested - Select one.
Breath
Blood
Urine
How much time elapsed from the time of the stop to the time of the test administered by the police?
If known, what was the time of the test or tests?
Supply all other information you think I should consider:
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