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Personal Details:

 

 

Surname:

 

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Date of birth:

 

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Contact Details:

 

 

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Offence Details:

 

 

Date of the offence:

 

What was your blood alcohol reading?

 

Is this your first Drink Driving Offence?
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If no, what year was the previous offence?

 

Did you restore your licence after this Drink Drive Offence?

 

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