UT Arlington Formal Student Appeal Form

Contact Information
Today's Date Today's Date / MM / DD YYYY
Current Time Current Time : HH MM AM/PM
Name Name First Last
Student ID Number
Email
Current Address Current Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Permanent Address Permanent Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Home Phone - ### - ### ####
Work Phone Work Phone - ### - ### ####
Cell Phone Cell Phone - ### - ### ####
Incident Information
Name of Group, Department, or Individual
Against Whom the Complaint was Filed:
Location of Incident
Date of Incident Date of Incident / MM / DD YYYY
Time of Incident Time of Incident : HH MM AM/PM
Statement of Appeal
Please describe, in your own words and in detail, the basis of your appeal. Include the appropriate names, departments, and/or groups involved in this case and the specific reasons for your appeal. Attach documents (photos, reports, e-mail, etc.) that provide evidence of procedural irregularity or differential treatment.
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