Evaluation Request
D.A. Wynne & Associates, Inc.
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Full Name *
Date of birth *
Home address
Phone number *
Email address
Type of arrest *
BAC level (if applicable) *
How many times have you ever been pulled over for driving under the influence of alcohol and or drugs? *
What county did the offense happen in? *
Referral Source
Who is your lawyer?
Who is your probation officer?
 What would be the best time to contact you *
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