DMV DL804

Participant's Certification of DUI Program Enrollment or Completion

Name(Required)

First Middle Last

Driver's License Number(Required)

Phone(Required)

Program Type(Required)

Education Only (23140 CVC Conviction)

First Offender Program

Multiple Offender Program

First Offender - How many months?(Required)

Multiple Offender Program(Required)

18 Months

30 Months

18 of 30 Months (IID Restriction Only)

Are you Enrolling or Completing a DUI Program?(Required)

Enrolling

Completing

Enrollment Date(Required)

DL 107 Certificate Number(Required)

Completion Date(Required)

DL 101 Certificate Number(Required)

Electronic Signature Agreement(Required)

I understand that by signing below, I am electronically signing this document and agree that my electronic signature is the legal equivalent to my handwritten signature.

E-Signature(Required)

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Date Signed

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IP Address