ATLANTA POLICE DEPARTMENT

APPEAL WAIVER

OPS CONTROL #:

I, accept full responsibility for violation of the following employee work or other rule(s) or ordinance(s):

Of the Atlanta Police Department or City of Atlanta, as outlined in Office of Professional Standards Complaint File Number . I concur with the disciplinary action of:

imposed by the Atlanta Police Department in my disciplinary case. With this my concurrence, I voluntarily, without coercion or duress, waive any and all of the right(s) I may have to appeal the above described disciplinary action taken in this case, either to the Civil Service Board of the City of Atlanta, or by way of administrative grievance, or by use of any other administrative or judicial remedy that may be available to me.

EMPLOYEE AND WITNESS SIGNATURES
EMPLOYEE SIGNATURE
DATE

WITNESS SIGNATURE
DATE

APPROVED BY DISCIPLINARY AUTHORITY

DISCIPLINARY AUTHORITY SIGNATURE AND TITLE
DATE

P - ______ - ______ - ______

Atlanta Police Department

Disciplinary Manual Page 1

Form APD-837 revised 1/1/2000

ATLANTA POLICE DEPARTMENT

VWarnic

2003-12-29

AJordan

APD