DWI-Ed Personal Data Form & NDP

PERSONAL DATA FORM
NAME:*

First NameMiddle NameLast Name
Drivers License #*
State*
SSN #*
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number*
Please enter a valid phone number.
How many times have you been married?*
How many dependents, other than yourself live with you?
Adults*
Children*
Do you feel your drinking or drugging has contributed to family problems at any time in your life?*

YesNo
If yes, why?

EDUCATION
How many years of schooling completed?*
Highest school grade completed?*

NoneGED/HS DiplomaBachelorsMastersDoctorate
EMPLOYMENT
List all jobs you have held in the past 3 years, beginning with your present job. Give a description of the type of job, year of employment, and reason for leaving.
How much total time were you unemployed in last 3 years?*

ARREST INFORMATION
Dates of current and previous arrest and charges:
Cause #*
Probation Officer*
If charged with DWI, what was the BAC?
Present Arrest Others
Prior to this arrest, was your license...*

OkSuspendedRevokedBusiness purposes only
Reason:*
Your age when you...
...began drug activities
...began drinking alcohol
...were arrested for first offense
...were arrested for first drug-related offense
What are your drugs of choice?:*

CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION

**SAMPLE** (This is a sample. Programs should consult with their legal counsel in regards to a consent form specific to their program.)
I,
authorize
(Name of the program)
to disclose to
(name of person or organization to which disclosure is to be made)
the following information:
(nature and amount of information to be disclosed)
The purpose of the disclosure authorized in this to:
(purpose of disclosure, as specific as possible)
I understand that all Offender Education Programs shall abide by and obtain any consent to disclosure required by applicable Federal and State laws regarding confidentiality of patient/client records including, as applicable and without limitation, 42 United States Code § 290dd-2; 42 Code of Federal Regulations, Part 2, and Health and Safety Code, Chapter 611. I understand my records cannot be disclosed without my written consent unless otherwise provided for by the regulations. I also understand that I may revoke this consent in writing at any time except to the extent that action has been taken in response to it, and that in any event, this consent expires automatically as follows.
(Specification of the date, event, or condition upon which this consent expires)
Date:
Signature of Participant*

Clear
Signature of Parent, Guardian, Authorized Representative, where required

Clear

PERSONAL DATA FORM