Court Referral for Court Approved Alcohol Testing Program

Name: __________________________________________	 		Date of Birth: ____________________
Address: _______________________________________________________    	Phone#: _________________________
Driver’s License #: __________________________________   Driver’s License State: ____________________________ 
Case #: ___________________   Charge/Offense: _________________________________________________________
Court: _________________	Judge: ____________________________	Court Phone#: ____________________ 	
Fax:   ___________________
Law enforcement agency:  _________________________	Prosecutor:  ________________________________
Court Approved Alcohol Testing Program is a condition of  	 bond		sentence

Register at:

	_________________________________________ 
_________________________________________
_________________________________________
______________________, MT
Phone:  ____________________________________	 

	_________________________________________ 
_________________________________________
_________________________________________
______________________, MT
Phone:  ____________________________________	

ORDER:	
	 Defendant must enroll in the court approved alcohol testing program by ______________________.
	 Defendant’s completion date is:
		  until _________________________________	  for _____________________________ days
		  until further order of court
	 The court approved alcohol testing program must file proof of enrollment within 24 hours of enrollment.
 Defendant MUST FILE PROOF OF ENROLLMENT OR APPEAR IN COURT ON __________________________, _______________________________, 201___, at _______ __.m. and explain why you did not enroll.
 Any non-compliance will be reported to the court or monitoring agency and may result in a warrant being issued for your arrest, your driver’s license being suspended, and your bond or suspended sentence being revoked.
 Must be randomly tested a minimum of ____ times per day
 Defendant is responsible for scheduling the initial appointment, compliance, and payment for services. 
 Defendant must abide by all program rules.  
 The court approved alcohol testing program must email Noncompliance reports to:
	___________________			___________________
	___________________			___________________					

Signature of Defendant    			   Date		              Signature of Judge				Date

___________________________________________ Office Use Only __________________________________________________  

 did	  did not  enroll with program    	Signed:  _______________________________  Dated:  _______________

cc: ____________  City Prosecutor    Defendant  Defendant’s attorney __________________	 Program _______________