Report to the Chancellor

RE: Withdrawal of Consent to Remain on Campus

This will notify you that, in conformance with authority you delegated to me I have withdrawn consent to remain on campus of the University of California, Irvine, from the following individual:

Name:

Address:

Telephone:

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.

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as hereinabove described are such exigent ones that the continued presence on campus of the person from whom I have withdrawn consent constitutes a substantial and material threat of significant injury to persons or property.