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Application for Appeal of Traffic Citation

(ALL APPEALS MUST BE MADE WITHIN 10 DAYS!)

NOTE TO APPLICANT: A patron may appeal a violation citation within 10 business days of issuance of citation. If you intend to be present at the hearing, you will be notified by the Appeal Board of the date, time, and place it will be held.

Failure to appear without advance notice will result in your case being considered in your absence and the decision of the board will be binding.

Today's Date: (mm/dd/yy)
Your Name (first middle last):
Your Street Address:
City:
State:
Postal or Zip Code: (xxxxx-xxxx)
Country: (if not USA)
Your Daytime Phone: (xxx-xxx-xxxx)
Your E-Mail Address:
Your UTC ID: (no dashes)
Your UTC Classification:
Your License Tag State:
Your License Tag Number:

Decal Number (if known):

Citation Number(s):

Reason for Appeal:

Select one: (Faculty is exempt from appearing)
I have read the above and understand its meaning and have supplied factual information requested to the best of my ability.