AAIM : Alliance Against Intoxicated Motorists

AAIM'S DRUNKBUSTER REPORTING FORM
(Reporting form must be received by AAIM within 45 days of arrest
to be eligible for award)

FROM:	Police (Name of Department)
ADDRESS:
CITY:
STATE:
ZIP CODE:

1. Name of citizen reporting the DUI:
NAME: (please circle Mr. or Ms.)
ADDRESS:
CITY:
STATE:
ZIP CODE:
TELEPHONE:

2. Date and Time of DUI arrest: (taken from police report)
County of Arrest

3. Arresting Officer's name:
Arrest Report #:
Phone #:

4. Optional Information:
BAC Level:
Field Sobriety Refusal:	YES NO
Was there a near-miss, crash, injury or fatality? YES NO
Other notable facts?

This form is to verify that the person named above on line #1 reported a possibly impaired driver who was subsequently arrested for operating a motor vehicle while intoxicated.

Signed: Date: (Police Official)

Please send or FAX this form to:

Alliance Against Intoxicated Motorists
870 E. Higgins, Suite 131
Schaumburg, IL 60173
(847)240-0027 PHONE
(847)240-0028 FAX

Questions to be answered by Drunkbuster Awardee:

Would you be willing to talk to a media representative about this incident?
YES NO
How did you learn of the Drunkbuster Program?
Police Newspaper Other

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