3565: Termination of Driving Privileges

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Full Name (at time of attendance)

Graduation Year or Year Last Attended:

Birthdate

Address

City

State

Zip/Postal Code

Phone Number

How would you like your transcripts delivered?

Fax Number (If fax delivery chosen)

Does your transcript need to be sent to a 3rd party? (to a college, university, employer, etc.?)

If yes, where?

Address (of the 3rd party)

City

State

Zip/Postal Code

Email (of the 3rd party)

Please initial below to acknowledge that you are the student named above and that you have reviewed the information above and agree that it is accurate. By initialing below you endorse this document as legally binding in accordance with the e-sign bill S.761 and release the below initials in lieu of a signature.

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