Name:  ______________________________             Date of Violation: ______________________   

Campus Box: _________________________            Ticket Number: ________________________

Address: ____________________________              License Plate: ________________________

__ ___________________________________           College Decal No: _____________________

IMPORTANT: Your copy of the Motor Vehicle Violations ticket must accompany your appeal and be
received in the Safety and Security Office (Rich Hall, Lower Level) within two days
of the violation.  You will receive written notice indicating the action taken by the
Appeals Committee.

Explanation of Appeal: (Please Print on form)

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                                                                Signature of Appellant:_____________________________

                                                                                           Date:____________________________

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Department/Committee Use Only