CCI ENROLLMENT INFORMATION & CONSENT DOCUMENT

ENROLLMENT INFORMATION

Informed Consent & Agreement
Hello,

Thank you for reaching out to our program. We know this can be a difficult time, and our staff is here to guide you through the process. Please complete the attached information as accurately as possible. Once received, we will verify your program needs with the DMV Mandatory Actions Unit (MAU). Accurate details will help prevent delays with both DMV and court requirements.

After verification, we’ll contact you by phone or email to schedule your enrollment appointment—please watch for our message. Please look through the Q&A page and our wesite to become more familiar with the program.

For questions about the return of your license, you may also contact DMV-MAU directly at 530-916-6525. We look forward to assisting you.
Todays Date*

MonthDayYear
Enrollment request date
Name*

First NameMiddle NameLast NameSuffix
Drivers License Number*
ID number is acceptable also
Date of birth*

MonthDayYear
DOB
Address*

Street Address

Apt or Suite #

CityState / Province

Postal / Zip Code
What town did you get your DUI in?
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
How many dui's do you have?*
Have you attended our program before?*

YESNO
Are you reinstating into our program after a termination?*

YES (I am hoping to pick up where I left off)NO (this is a new enrollment)
What is the date of your most recent DUI violation?*

MonthDayYear
It is important that this date is correct
What program do you need to take?

12 Hour Education Only (DMV is not involved)3 Month First Offender Program6 Month First Offender Program9 Month First Offender Program18 Month Multiple Offender Program
Have you been sentenced and convicted in court? do you have a Court referral?

Yes (You will need to provide your paperwork for us to notify the court)NO (My case is still pending)I do not know I am taking care of an old DUI for DMV only
I want to attend...

Live Virtual Services Using the Zoom PlatformIn Person at the local officeI am not sure need to discuss further
I verify that the information provided above is accurate. I confirm that I have read and understand the Informed Consent and Agreement document related to my DUI program enrollment.

I acknowledge that, in some cases, the DMV-MAU or the court may amend the required length of my program. I understand that I am financially responsible for all DUI program services I receive.
Participant Signature

Clear
Additionally, I understand that a Transfer-In fee of $135 may apply if there is a change to the length of the program in which I am or was originally enrolled.
Initial

Clear
__________________________________________________________

OFFICE USE ONLY: Completed by:______________________

_______ Checked computer for name before entry-CLIENT # _________________

______ DL107 COMPLETED & ATTACHED

______ SCHEDULE COMPLETED, EMAILED & ATTACHED

___ PROGRAM CALLED DMV - Representative Name: ______________________

Last Violation Date per DMV: ______________ Length of Program:____________

___ Court Paperwork Attached - County Court Name: _____________________

Length of Program Ordered: _______ Docket # ____________________________

Does the arrest date match DMV arrest date?____________

Notes Regarding Enrollment & Needs:
Should be Empty: