SELIGMAN UNIFIED SCHOOL DISTRICT # 40

P.O. BOX 650

SELIGMAN, AZ 86337

500 N. MAIN

PHONE(928)422-3233

FAX(928)422-3542

Date:_____________________

Student Name:__________________________Grade:__________________________

Date of Birth:___________________________

The pupil above is now enrolled in our school. Please send the following information to our school district as soon as possible:

• Official Notice of Student Withdrawal
• Cumulative Records
• Complete Transcript of work done at your school
• Health and Immunization Records
• Special Education Files
• Discipline Records
• Psycho-educational Records

Remarks:

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Thank You for your cooperation.

Kathleen S. Cothrun

Registrar

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Parent/Guardian Signature Date