DWI Form
General Information
Name: _____________________________________________________
Address: ______________________________________________________________
Phone Number: _____________________ Date of Birth: ______________
Purpose of Assessment: _______________________________________
Number previous DWI charges/convictions: __________
Pre-trial_____ Post-trial_____
State Driver License #: ______________ Date of arrest: _________________
Date of conviction: _________________ County of arrest: ______________________
Attorney: _________________________ Probation Officer: _____________________
How did you hear about ASI?:____________________________________________
Date and time of appointment requested:___________________________________
Please remember to bring the following:
Photo ID/Driver License # |
|---|
Ticket, BAC verification, judgement/310form (if convicted) |
Previous assessment, if applicable |
Assessment Fee |
______________________________________________________________________
Please fill out and sign the below to allow us to order your driving record.
Please allow Addiction Solutions, Inc. to order my North Carolina individual Motor Vehicle Record from the Department of Motor Vehicles for the purpose of completing a DWI assessment.
Full Name: ____________________________________________________________
NC Driver License Number: __________________ SS#: _______________________
Today's date: __________________
Signed: _______________________________________________________
