Code:   JHFDA-AR(1)


                             Request for a Suspended Driving Privilege - Conduct


Name of Student                                                                                                                          


Address of Student                                                                                                                       


Date of Birth                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             ODL Number (if applicable)                                                                                                                                                    


Number of requests for suspension on this student: G one G two or more


Type of privilege requested for suspension:


G      Driving privilege

G      Application for driving privilege


Length of suspension requested:


G      No more than one year

G      Six months

G      Six weeks

G      Other


If two or more requests for suspension have been made on this student:


G      [Two years]

G      [         ]

G      Until student is 21 years of age


[Type of infraction:


G      Expelled for bringing a weapon on school property.

G      Suspended or expelled at least twice for assaulting or menacing a school employee or another student, for willful damage or injury to district property or for use of threats, intimidation, harassment or coercion against a district employee or another student, possessing, using or delivering a controlled substance or being under the influence of a controlled substance at a school or on school property or at a school-sponsored activity, function or event.]


This written request is submitted on                                  by:


Name:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Title:                                                                        


District:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Date: