A Public Service Agency Participant s Certification of DUI Program Enrollment or Completion (Instructions for completing this form are on the reverse side.) PROGRAM PROVIDER NAME: PARTICIPANT NAME:.
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How to fill out the DL 804 online
Filling out the DL 804 form is an essential step for participants in a DUI program to certify their enrollment or completion. This guide provides clear, step-by-step instructions to help you accurately complete the form online.
Follow the steps to fill out the DL 804 form online
- Click ‘Get Form’ button to initiate the process and open the form in your browser.
- In the 'PROGRAM PROVIDER NAME' field, input the name of the organization that provided the DUI program.
- Fill in the 'PARTICIPANT NAME' section with the participant’s last name, first name, and middle initial.
- Enter the provider’s ADP license number in the designated field to identify the program provider.
- Specify the participant's driver license number or ‘X’ number accordingly.
- Choose the appropriate 'PROGRAM TYPE' by selecting the relevant option: 'Education Only,' 'Multiple Offender Program,' or 'First Offender Program.'
- Indicate the 'ENROLLMENT DATE' by entering the relevant date of enrollment.
- For program duration, select the duration option that accurately reflects the program: 18 months, 30 months, or 18 of 30 months for IID restriction only.
- Input the 'COMPLETION DATE' if the program has been completed.
- Fill in the 'DL 107 CERTIFICATE NUMBER' or 'DL 101 CERTIFICATE NUMBER' if applicable.
- Sign the form as a participant by entering the 'PARTICIPANT’S SIGNATURE.'
- Provide the telephone number in the specified field to ensure proper communication.
- Once all information is accurately filled out, save changes. You have the options to download, print, or share the completed form as needed.
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