Contact Information:

First Name
Last Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Phone Number
E-mail

Vehicle License Number:

State Vehicle Licensed in:

Vehicle Make:

Vehicle Model:

Vehicle Color:

Date of Violation:

-- mm/dd/yy

Location of Violation:

I am primarily (please choose one):

Student
Faculty/Staff
Community Member

I submit the following facts/circumstances in support of this appeal: