Date ____________________
To ______________________________
You are hereby notified by the undersigned, a person designated by the Chancellor of the Irvine Campus of the University of California to maintain order on such Campus, that your consent to remain on the Irvine Campus has been withdrawn.
You are further notified that, if you should remain on Campus or should return to the Campus within 14 days of this warning without specific consent to do so, you may be found guilty of a violation of Section 626.4 of the Penal Code of the State of California.
Signature______________________________
Time and date of withdrawal of consent______________________________