1-800-473-OHIO (6446)

Already registered? Click here to pay.

Access DUI Class Registration

Personal Information

Location:*

Room Date:*

Room Type:*

First Name:*

Last Name:*

Birth Date (mm/dd/yyyy) / Age:*

Gender:*

Email Address:*

Primary Phone:*

Work Phone:*

Address:*

City:*

State:*

Zip:*

Do You Smoke?:*

Ethnicity:*

Job Type:*

Employment Status:*

Highest Grade Completed:*

Who Referred You To Access?:*

Information Regarding Your Offense

Type Of Offense:*

Referring Court:*

Breathalyzer Results:*

Other:*

Have you had prior arrests?:*

Case Number:*

Blood Test:*

If yes, were any a DUI:

Urine Test:*

Prior Arrests - List Dates and Details:*

Attorney Information

First Name:*

Last Name:*

Phone Number:*

Address:*

City:*

State:*

Zip:*

Emergency Contact Information

First Name:*

Last Name:*

Phone Number:*

Relationship:*

Address:*

City:*

State:*

Zip:*

Physician Information

First Name:*

Last Name:*

Phone Number:*

Address:*

City:*

State:*

Zip:*

Have You Ever Had...


All content Copyright © 2012 Access Ohio
2935 Hamilton Mason Road
Hamilton, OH 45011
1-800-473-OHIO (6446)
P: (513) 868-2390
F: (513) 868-2267