Participant's Certification of DUI Program Enrollment or Completion DL 804

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This form is to be completed and used only by a licensed DUI Program Provider.

When the program provider is unable to capture the participant’s signature on the paper version of either the DL 101 or DL 107 certificate, or if the provider is submitting an electronic certificate, the DL 804 must be used to capture the program participant’s signature, certifying under penalty of perjury that the participant has either enrolled in or completed the required DUI program.

When completing the form:

  1. If completing the form manually, please type or print legibly using a ballpoint ink pen.
  2. The program provider name should match the "business program name" as licensed by the Department of Alcohol and Drug Programs (ADP).
  3. Include the provider’s ADP ten-digit license number.
  4. The participant’s name should appear as it does on the driving record and on the DUI certificate.
  5. Include all the information pertaining to the participant’s program.
  6. Capture the participant’s signature and date signed in ink.
  7. Include the participant’s day telephone or message number.
  8. Read the instructions below the DL 804 form.
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