This will notify you that, in conformance with authority you delegated to me I have withdrawn consent to remain on campus of the University of California, Irvine, from the following individual:
Status: __UCI or UC student __faculty member __staff personnel __nonstudent
The circumstances giving rise to the withdrawal of consent are as follows:
Withdrawal of Consent to Remain on Campus was issued on ______________________ at ________________o'clock.
If not reinstated by you, the Withdrawal of Consent expires on ______________________ at ________________o'clock.
Written notice of Withdrawal of Consent has/has not been sent.
Date & Time __________________________________
I find that the circumstances as hereinabove described are such exigent ones that the continued presence on campus of the person from whom I have withdrawn consent constitutes a substantial and material threat of significant injury to persons or property.