Forms must be submitted to Security within 48 hours of the issue date on the citation.

1. Is this vehicle registered in your name?
    Yes No

If no, give registered owner's name and address.

Owner's Name

Relationship

Owner's Complete Address

2. Your Information

Name

Your Complete Address

Home Phone

E-mail Address

3. Are you:
        Faculty/Staff

        Student     Program  

        Other

4. Enter the following information from your copy of the citation.

5. State your reason for the appeal
       

By submitting this form, you are affirming this statement is true and accurate to the best of your knowledge.