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UConn Health Parking Citation Appeal Form

Contact and Vehicle Registration Information
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone
Email*
Name of Registered Owner*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Reason for Parking on Campus
Select one:*
- Contractor
- Emeritus/Retiree
- Employee Area 1
- Employee Area 3
- Patient/Visitor
- Resident/Fellow
- Student
- Volunteer
Permit Number (if applicable)
DMV Handicap Permit Number (if applicable)
Ticket and Vehicle Information
Ticket Number*
Date Issued*
MM
DD
YYYY
Type of Violation*
Vehicle License Plate Number*
State License Plate Issued*
State
Parking Location*
Reason for Appeal
Please describe the reason for your appeal.*
Copy of Citation