Code:   JHFDA-AR(2)




                                                         Notice of Withdrawal



Student Name (Print Last, First, Middle)


Student Address                                                                                                                                       City                                State                 Zip Code


Date of Birth (MM/DD/YYYY)

Oregon Driver License/ID Number (If Known)

Last Day of Attendance (MM/DD/YYYY)



I hereby notify the Department of Transportation to suspend the driving privileges of the above named student because the student is considered to have withdrawn from school per ORS 339.257 (2).  The policy adopted under ORS 339.257 meets all requirements of the law including: The number of days of unexcused absence; the age of the student; and, a provision allowing the student to appeal this decision.


Name of School District or Private School

Telephone Number

(         )

Address                                                                                                                                                    City                                State                 Zip Code



      Q School District Superintendent                        Q School Board Member/Superintendent                        Q Authorized Representative of Private School

Name of Authorized Person (Please Print)







735-7186 (-00)                               White copy to DMV, Yellow copy for your records                               STK# 300161