Name:

Address:

City:

State:

Zip:

Email Address:

Phone Number:

Booking Number:

Driver's License Number:

Court Date:

Time:

Court Name:

Division/Room:

Arresting Officer's Name and Badge:

City of Arrest:

What specific drug offense were you arrested for (include Code/statute section, if known)?

Have you been convicted of a drug violation before?

Yes

No

If yes, when?

Describe the circumstances of the past drug violation and your sentence, if any

Have you been convicted of other offenses?

Yes

No

If yes, what and when?

Have you been through drug treatment in the past?

Yes

No

Are you on probation or parole?

Yes

No

For what?

Do you have any other cases pending?

Yes

No

Was anyone else arrested?

Yes

No

If so, name(s) of all persons arrested:

What statements do you remember making to the police about the alleged drug offense?

Describe the order of events leading up to the arrest:

Have you discussed the alleged drug offense with anybody else?

Yes

No

If so, whom did you discuss it with and what did you tell them?

Were there any witnesses to the alleged offense?

Yes

No

If yes, provide names and contact information if known:

What is the amount of the bond you posted?

Are there any special bond conditions?

Were you referred by somebody else?

Yes

No

Who?

Special Concerns:

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