Full IGN:
When did you get banned?: (You can put either the exact date or a relative time from when you were banned)
Who banned you?: (Who banned you, simple enough)
Why did you get banned?: (Don't use this to complain. Do your best to explain your side of the story and don't excessively talk crap out of anger)
There is no guarantee that action will be taken right away, but your request will be reviewed soon.