Fillable Admin Review Admin Review (California State University, Dominguez Hills)

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Admin Review Admin Review (California State University, Dominguez Hills)

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Parking Services • (310) 243-3725 • Carson, CA 90747
REQUEST FOR ADMINISTRATIVE REVIEW
(Please Print)
Name __________________________________________ Citation #: ________________________
Address: ________________________________________ Date Issued: _______________________
City / State / Zip: _________________________________ Vehicle License #: __________________
Phone #: Home ( ____ ) ___________________________ Work ( ____ ) _____________________
☐ Student CSUDH Permit # _________________ Location Posted: ___________________
☐ Employee CSUDH Permit # _________________ Location Posted: ____________________
☐ Visitor CSUDH Permit # _________________ Location Posted: ____________________
Please state why you believe the citation should be rescinded: _____________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
If more space is needed, please attach a separate sheet of paper. Attach any relevant material(s).
Signature: _________________________________________________ Date: _________________________
*** FOR OFFICE USE ONLY ***
Officer Comments: ________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
The facts above have been reviewed by the issuing officer and their supervisor. The above referenced citation
HAS ☐ HAS NOT ☐ been recommended for dismissal.
Issuing Officer: ________________________________________ Date: ______________________
Supervisor: ____________________________________________ Date: ______________________
☐ Issuing officer unavailable to review citation. Referred to Hearing Officer for adjudication.
Hearing Officer’s decision to be mailed to you separately.
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Admin Review Admin Review (California State University, Dominguez Hills)

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Completed 31 August 2021

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