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Print last name, first initial <br /> DIRECTIONS: Please circle the correct response (YES or NO) to the following <br /> questions and provide details where requested. <br /> SECTION 2.B. ALCOHOL USE <br /> ABOUT HOW OFTEN DO YOU HAVE 6 OR MORE ALCOHOLIC DRINKS IN A SINGLE AFTERNOON OR <br /> EVENING? (NUMBER OF TIMES PER YEAR) <br /> WHEN WAS THE LAST TIME YOU HAD 6 OR MORE ALCOHOLIC DRINKS IN A SINGLE AFTERNOON OR <br /> EVENING? <br /> NO YES HAVE YOU EVER PURCHASED ALCOHOL FOR A MINOR? <br /> SECTION 3A. LEGAL HISTORY: ARRESTS AND OUTCOMES <br /> NO YES HAVE YOU HAD AN ARREST EXPUNGED, SEALED OR OTHERWISE REMOVED FROM YOUR <br /> RECORD? <br /> NO YES HAVE YOU EVER BEEN ARRESTED? IF YES, HOW MANY TIMES? <br /> PLEASE PROVIDE THE DETAILS REQUESTED BELOW, FOR EACH OCCURRENCE. <br /> (DO NOT LIST ROUTINE TRAFFIC TICKETS, BUT DO LIST INCIDENTS SUCH AS DUI'S, <br /> DWAI'S,AND RECKLESS DRIVING.) <br /> DATE OF ARREST: <br /> ORIGINAL CHARGES: <br /> OUTCOME: CHARGES DROPPED WITHOUT TRIAL, TRIAL AND ACQUITTAL <br /> PLEADED GUILTY OR NO CONTEST TRIAL AND CONVICTION <br /> PROBATION $ FINE JAIL - COMMUNITY SERVICE <br /> OTHER. SPECIFY: <br /> DATE OF ARREST: <br /> ORIGINAL CHARGES: <br /> - OUTCOME: CHARGES DROPPED WITHOUT-TRIAL TRIAL AND ACQUITTAL -- <br /> PLEADED GUILTY OR NO CONTEST TRIAL AND CONVICTION <br /> PROBATION $ FINE JAIL COMMUNITY SERVICE <br /> OTHER. SPECIFY: <br /> IF YOU WERE ARRESTED OR CONVICTED MORE THAN TWO TIMES, PLEASE USE THE BACK OF THIS FORM <br /> OR A SEPARATE SHEET OF PAPER FOR ADDITIONAL INFORMATION. <br /> NO YES As A STUDENT AT A COLLEGE OR UNIVERSITY, HAVE YOU EVER BEEN DISCIPLINED FOR <br /> MISCONDUCT, SUSPENDED, EXPELLED, OR REQUIRED TOWITHDRAW, FOR ANY REASON? <br /> If Yes: Year University REASON <br /> Disciplinary Action: <br /> (c) Law Enforcement Psychological Services, Inc. (408) 356-9696 <br /> Rev Date April 2009 Post_PsyQ Supp NY.doc <br /> PSS/LEPS PLLC 51 <br />