UNIVERSITY OF NORTH CAROLINA AT CHARLOTTE
DISCIPLINARY REFERRAL

Today's date:
(example: 01/01/2002)
Accused name: Reporting Person:
Last:
First:		 Last:
First:
Local Address: Local Address:
Street:            City:               
State, Zip:   

Street:                
City:                   
State, Zip: 
Telephone Number:
(example: 704-687-2000)
 Telephone Number:
(example: 704-687-2000)
Briefly describe the incident in question:
Briefly state what remedy or resolution you are interested in seeking:

Other persons involved whom we can contact and their telephone numbers:

Name:

Telephone number:

I am hereby requesting that the University Advocate or the Dean of Students Office investigate the above-described matter. I authorize the office of the University Advocate or the Dean of Students Office access to relevant documents, records, and other evidence needed to complete this investigation.      Name: