DUI Program Pre-Enrollment Form

Title*

Mr.
Mrs.
Ms.
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Date of birth *

Race*

Caucasian
African American
Hispanic
Asian - Pacific Islander
Other
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Gender*

Male
Female
Other
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What Is Your Preferred Language?*

English
Spanish
Other
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Relationship To You*

Parent
Spouse
Child
Sibling
Friend
Other
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Violation Date *

Conviction Date *

Do You Have More Than One DUI?*

Yes
No
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More Than One DUI Date

What Is Your Client Type?*

New Client
Transfer-In
Change Of Program
Reinstatement
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What Location You Are Interested In Enrolling?*

Vallejo
Fairfield
Vacaville
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