Instructions for Completing the Participant's Certification of DUI Program Enrollment or Completion (DL-804)
This form is to be used under the following circumstances:
This form captures the participant's signature, which certifies under penalty of perjury that the participant has either enrolled in a DUI program, or completed the required DUI program. This signature would normally be on the DL 101 or DL 107, but in the above circumstances you may not be able to capture the participant's signature on the certificate. Please, ensure that the information on this form is consistent with the information on the Proof of Enrollment Certificate (DL 107) or the Notice of Completion Certificate (DL 101) you submit for the identified participant.You must retain this form in your office in a manner that will allow you to retrieve it by searching for the serial number of the corresponding Certificate (DL 107 or DL 101) and for the period required by Section 9866 of title 9, California Code of Regulations. On the printed Notice of Completion Certificate (DL 101) you submit without a participant's signature, type or print the words "Signed DL 804 in file" in the space provided for participant's signature.
Do not submit a DL 804 to OMV unless you are requested to do so. DL 604 (REV. 112003)
ENTER THE FOLLOWING INFORMATION AND SIGN BELOW.
PROGRAM PROVIDER NAME: Second Chance Inc. PROVIDER'S ADP LICENSE NUMBER: 01-003-01-100
PARTICIPANT'S NAME: DRIVER LICENSE NUMBER OR "X" NUMBER:
DO NOT COMPLETE THIS SECTION. ADMINISTRATIVE USE ONLY.
ENROLLMENT DATE: DL 107 CERTIFICATE NUMBER:
COMPLETION DATE: DL 101 CERTIFICATE NUMBER:
I certify under penalty of perjury under the laws of the State of California that I have enrolled in, or completed the program as indicated above.
PARTICIPANT'S PHONE NUMBER:
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: DMV DL-804
Agree & Sign