Participant's Certification of DUI Program Enrollment or Completion

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:

• When a program participant has completed all the required DUI Program components, but you are unable to immediately issue a Notice of Completion Certificate (DL 101) and capture the participant's signature on the (paper) completion certificate.
• When a program participant has completed all the required DUI program components and you are submitting an electronic Notice of Completion Certificate (DL 101) via an authorized Internet access link with the Department of Motor Vehicles (OMV).
• When a program participant has enrolled in a DUI program and you are submitting an electronic Proof of Enrollment Certificate (DL 107) via an authorized Internet access link with the OMV.

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:  

PROGRAM TYPE: 

DO NOT COMPLETE THIS SECTION. ADMINISTRATIVE USE ONLY.

ENROLLMENT DATE:     
DL 107 CERTIFICATE NUMBER: 

OR

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: 

DATE:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Signature Certificate

Document name: DMV DL-804

Unique Document ID: 3f5f74578bb5423184d0ed14d348b58e04a1b519

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Timestamp	Audit
March 16, 2021 2:37 pm MDT	DMV DL-804 Uploaded by Jenna Pleadwell - Jpleadwell@screcovery.org IP 72.208.210.34
March 16, 2021 5:09 pm MDT	Document owner janiceadayforbes@gmail.com has handed over this document to Jpleadwell@screcovery.org 2021-03-16 17:09:45 - 73.96.29.235

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