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TOBACCO APPEAL
PLEASE PRINT CLEARLY AND FILL OUT ALL INFORMATION.
INCOMPLETE APPEALS CANNOT BE PROCESSED.
Mail to: PCC Public Safety, PO Box 19000, Portland, OR 97280 Attn: Tobacco Appeals
PLEASE CHECK ONE: □ FIRST APPEAL □ SECOND APPEAL
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Name Date Submitted
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Address Student ID Number
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City State Zip Ticket Number
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Phone Number Ticket Date
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Email Address
Check one:
I am a: □ Student □ Employee □Visitor
Please explain the circumstances regarding your ticket below and provide any evidence supporting your claim. Appeals must be submitted within 21 calendar days of being issued a ticket. Late appeals will not be accepted. Please allow two weeks for the Director of Public Safety to notify you via email of the appeals decision.
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Appeal has been: □ Approved □ Denied □ Reduced to $_____ Total amount due ____________
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