PARKING AND TRAFFIC VIOLATION APPEAL FORM - DOC

							                                GALLAUDET UNIVERSITY
               PARKING AND TRAFFIC VIOLATION APPEAL FORM
THIS FORM MUST BE COMPLETED AND SUBMITTED TO THE DEPARTMENT OF PUBLIC SAFETY, CARLIN HALL,
WITHIN SEVEN CALENDAR DAYS OF THE DATE OF THE TICKET. APPEALS RECEIVED AFTER SEVEN DAYS WILL
NOT BE CONSIDERED. THE APPELLANT WILL BE NOTIFIED IN WRITING OF THE DISPOSITION OF THE APPEAL.

NAME OF APPELLANT: __________________________            Student    Faculty/Teacher/Staff    Visitor/Other

         STUDENT/FACULTY/TEACHER/STAFF                                     VISITOR/OTHER

   CAMPUS MAILING ADDRESS:                                  MAILING ADDRESS:
   __________________________________________               ________________________________________
   E-MAIL ADDRESS: _________________________                ________________________________________
   TELEPHONE NUMBER: _____________________                  ________________________________________

VEHICLE/TICKET INFORMATION:

LICENSE PLATE #:____________________________                STATE REGISTERED: _____________________
VEHICLE MAKE:______________________________                 MODEL:_________________________________
TICKET #: ___________________________________               DATE ISSUED: ___________________________
VIOLATION: _________________________________                LOCATION:______________________________

PARKING REGISTRATION INFORMATION:

    Student Permit #: _________________________                 Temporary Permit-Expiration Date: ________
    Faculty/Teacher/Staff Permit #_______________               No Campus Registration

REASON FOR REQUESTING CANCELLATION OR WAIVER.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Signature:__________________________________________ Date: ____________________________________
                                         DPS USE ONLY

Date Appeal Received in DPS: ______________________________ (if the appeal is received after seven days
from the date of the ticket, it will not be considered.)

Disposition:               Appeal Denied          Changed to Warning         Ticket Cancelled/Waived
Comments: __________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Returned to Appellant (date):___________________________ Initials: _________________________________
NOTE: If the ticket has not been changed to a warning or cancelled or waived, it must be paid within seven
calendar days of the above date. If not, the fine will double.