Please Print Today’s Date ________________
University Official(s) _____________________________ Room ________ Phone ____________
_____________________________ Room ________ Phone ____________
Charged Student:
Name __________________________________________________ S.S.N. _______________
Home Address: Street____________________________________________________________
City_____________________________________________________________
Campus Address: Hall ___________ Room __________ Home/Campus Phone _____________
Violation Information:
Date _____________ Building Location _____________________ Time (military) _____________
Day of the week: Mon. Tue. Wed. Thu. Fri. Sat. Sun. Student’s RA __________
Charges: Handbook
Section No. Title
_______________ ________________________________________
_______________ ________________________________________
_______________ ________________________________________
_______________ ________________________________________
Comments:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
To the above charged student: As specified above, you have been charged with a violation of the Concordia University StudentConduct Code/ Handbook, hereafter called Conduct Code. As a student of this University, you have the right to an administrative hearingand, in this hearing, you have the right to take responsibility of violating the Conduct Code or you have the right to a hearing beforethe University Judicial Board (refer to your Student Handbook for a detailed explanation of all your rights). Your signature belowacknowledges that you have read this paragraph and that you understand that you are charged with violating the Conduct Code.
Signed__________________________________________________________Date______________
The above student was unable or unwilling to sign above and has been informed verbally of the above charge(s), as well as presented with the carbon copy previously attached to this form.
University Official_____________________________________________________ Date_____________________
