SHASTA COLLEGE

SHASTA COLLEGE
*Initial Administrative Review*
An initial Administrative Review may be requested in person, by phone, or in writing. Please be specific when explaining why you feel that dismissal of the citation is warranted.

			(Citation #)
PLEASE TYPE OR PRINT THE FOLLOWING;
			(Violation)
Respondent's Name: ___________________________
			(Date & Time Citation Issued)
Address: ___________________________________
			(Vehicle License #)
City: _________________Zip:________________
			(Permit # if Applicable)
*Violation Location:* _____________________________________________________________________________

Statement of Facts: _________________________________________________________________________________

___________________________________________________________________________________________________

____________________________________________________________________________________________________
(If more room is needed please attach a separate piece of paper)

Form Completed by: Circle one: Mail-In Phone-in In Person

Signature:_______________________________________Date:________/______/______

(For Office Use Only)
Reviewed by: ______________	ID #________		Date: ____/____/____

Citation Dismissed: _______________		Code: ____________________

Citation Valid:________________		Code: ____________________

Comments:____________________________________________________________________

Determination Mailed - Date: ____/____/____
Warning: If you wish to pursue this matter further please see the attached instructions. Failure to respond in a timely manner may prevent you from contesting this citation any further!

Signature: _______________________		Date: ____/____/____
Return to: Shasta College Information Desk - 100 Building, PO Box 496006 - Parking Division, Redding, CA 96049-6006 - ( 888) 300-9915 or (530) 242-7913 - FAX (530) 225-3905