Dmv Form Dl 804 – Fill Out and Use This PDF

A Public Service Agency

Participant’s Certiication of DUI Program Enrollment or Completion

(Instructions for completing this form are on the reverse side.)

PROGRAM TYPE
Education Only (23140 CVC Conviction)			First Offender Program			____ months
Multiple Offender Program		____ 18 months	____ 30 months			____ 18 of 30 months (IID Restriction only)
				OR
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.

DATE	PARTICIPANT’S SIGNATURE	TELEPHONE NUMBER
		(	)

DL 804 (REV. 1/2003)

Instructions for Completing the

Participant’s Certiication 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 Certiicate (DL 101) and capture the participant’s signature on the (paper) completion certiicate.

•When a program participant has completed all the required DUI program components and you are submitting an electronic Notice of Completion Certiicate (DL 101) via an authorized Internet access link with the Department of

Motor Vehicles (DMV).

•When a program participant has enrolled in a DUI program and you are submitting an electronic Proof of Enrollment

Certiicate (DL 107) via an authorized Internet access link with the DMV.

This form captures the participant’s signature, which certiies 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 certiicate.

Please, ensure that the information on this form is consistent with the information on the Proof of Enrollment Certiicate (DL 107) or the Notice of Completion Certiicate (DL 101) you submit for the identiied participant.

You must retain this form in your ofice in a manner that will allow you to retrieve it by searching for the serial number of the corresponding Certiicate (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 Certiicate (DL 101) you submit without a participant’s signature, type or print the words “Signed DL 804 in ile” in the space provided for participant’s signature.