Revised 4/26/17
PARKING CITATION APPEALS FORM
This form must be returned to Campus Police and Public Safety within 15 days of the citation issue date.
ENTER THE FOLLOWING INFORMATION FROM YOUR COPY OF THE CITATION
Decal Number: _____________________________________ Date Issued: _______________________________
Tag Number/State: __________________________________ Citation Number: ___________________________
Name: _____________________________________________ Student/Employee ID #: _____________________
Are you: ☐ Faculty/Staff ☐ Student Program _________________________ ☐ Other ________________
Mailing Address: _____________________________________ City: _____________ State: ______ Zip: _______
Is this vehicle registered in your name? ☐ Yes ☐ No If no, please provide owner’s information below.
Owner’s Name: ________________________________________ Relationship: ____________________________
Owner’s Address: ______________________________________ City: _____________ State: ______ Zip: _______
STATE YOUR REASON FOR THE APPEAL BELOW
(Attach additional pages, photos, or documentation if needed)
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I affirm this statement is true and accurate to the best of my knowledge.
Signature ___________________________________________ Date ____________________________________
Official Use Only:
Remarks: ______________________________________________________________________________________
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Disposition: ☐ Granted ☐ Denied ☐ Other _______________________________________________
Signature: ____________________________________________ Date: ___________________________
Director/Chief, Campus Police and Public Safety
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