513-868-2390

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Access DUI Class Registration

Personal Information

Location:*

Room Date:*

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Last Name:*

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

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Email Address:*

Language:*

Primary Phone:*

Work Phone:*

Address:*

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Do You Smoke?:*

Ethnicity:*

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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:*

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Emergency Contact Information

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Physician Information

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FEE AGREEMENT (REQUIRED)

I agree to pay the following fee for the Access Ohio DIP Program. Fee amount is $585.00 and is all inclusive. Hotel Room, Food, & Classroom Instruction.

I, agree to the above Fee Agreement.

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Hamilton, OH 45011
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