Personal Information
Full Name (Last, First, Middle): Driver's License State/Number: Phone Number:
Home Address (Number, Street, City, State & Zip): Return Email Address:
Student/Faculty/Staff/Administrator/Visitor: Banner Number: Parking Permit Number:
Campus Citation & Vehicle Information
Citation Number: Date Issued: Violation Number: Citation Issued at Which Campus:
Make of Vehicle: Model of Vehicle: License Plate Number: Color of Vehicle:
State your reason for appealing this Citation (A separate Appeals Form must be submitted for each Violation listed):
Please read and take note: By submitting this form, I understand that appeals will not be accepted more than 10 days after the
issuance of the Campus Citation. I also understand that the decision of the Chief of Police and/or the Appeals Committee is FINAL.
Submit this form as an EMAIL ATTACHMENT to the appropriate email address listed below:
San Antonio College Palo Alto College
St. Philip’s College Northwest Vista College
Southwest Campus Northeast Lakeview College
Failure to provide a valid return email address or FAX Number will result in rejection of the appeal request.
NOTE: For any inquiries regarding your appeal, send an email to the listed above email address. Once the decision is made
by the Appeal Committee, it is FINAL.
Appeal Denied Citation Dismissed
Appeals Committee Representative Name: or Police Department Representative: Name: Date:
Send to: Campus Citation
Appeals Committee at
Campus Where Citation Was
Issued (see below).