Mississippi College - Office of Public Safety

Statement of Appeal

One form must be completed for each citation in question. No appeal will be accepted 72 hours after the citation has been written (Saturdays, Sundays, and holidays excluded).

* = required field

Date of Appeal: 10-11-08

Citation Number*
(see right hand corner of citation)

Citation Date*

Classification*

Student ID* (xxx-xx-xxxx)
(Not required for Faculty/Staff)

First Name*

Middle Name

Last Name*

Campus Address (if applicable)

Box #

Dorm

Phone Number (xxx-xxx-xxxx)

Home Address

Street

City

Zip Code

Phone Number(xxx-xxx-xxxx)

Appeal:*
Use this space to state your appeal and any information pertaining to your case that may aid the Judicial Council in making its decision. Entering untrue statements will lead to further judicial action.

Electronic Agreement

All decisions will be finalized within two weeks. You will be notified by email of the Judicial Council's decision.

I affirm that the information given in this application is accurate and complete to the best of my knowledge. Additionally, I understand that entering untrue statements will lead to further judicial action.

In lieu of a signature, please check if you agree to the statement above and state your full name.
Full Name: