Certificate Of Attendance

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P.O. Box 80447
Conyers, GA 30013-8047
678-413-8400
Certificate of School Enrollment
Part A: Student Information
Student Legal Name (
):
Last, First, Middle
Address: _________________________________________________ State: _____ Zip Code: _______
Gender: __________________ Date of Birth: ___________________
Part B: School Information
School Name:
Phone #: ___________________
Address: _________________________________________________ State: _____ Zip Code: _______
Part C: Enrollment Certification
This record is to certify that the above named student is:
□ Enrolled in and not under expulsion from a public or private school.
Part D: Restoration of Driving Privileges Following School Suspension
This record is to certify that:
□ The above named student terminated his/her secondary education as of _____________ (date).
Please complete one of the following if a date is entered above:
o The student has re-enrolled in this school as of _____________ (date) OR
o The student will present proof of pursuit or completion of a GED, high school diploma, special diploma, or
certificate of high school completion, or proof of enrollment in a postsecondary school.
OR
□ The notice of school suspension/non-compliance was sent in error by this school.
Part E: Signatures
Certifying Official (PRINT NAME):
Official’s Title:
Original Signature:
Date:
Sworn to and subscribed before me this
day of
20
.
Signature:
Notary Public Seal
Within thirty (30) days, submit this original form to a Department of Driver Services Customer Service Center.
DDS-1 (3/16)

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