Administrative Penalty Notice Screening Request Form

*Please note: This form is not for disputing parking tickets.

Request for screening for non-parking related offences under the Administrative Monetary Penalty System.

Penalty Notice Recipient

First

Last

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Telephone Number

Email Address

Penalty Notice Information (Infraction)

Provide the information found on the Penalty Notice. Complete one Request for Screening form for each penalty notice.

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Penalty Notice Number

Penalty Notice Date

Offence Information

Type of Screening Requested

Electronic Telephone Conference

Correspondence

Please select your preferred Screening appointment time below:

Screening appointments will be heard every third Wednesday of every month.

10:00 AM - 12:00 PM

1:00 PM - 3:00 PM

Reason For Screening

Reason For Screening (Specifics Required)

Please provide a factual and detailed explanation of your reason(s) for your Screening Request:

Attachment(s)

Do you need to upload an attachment?

Yes

Upload your attachment(s):

One file only.
32 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

Statement of Penalty Notice Recipient

I represent and warrant that:

All information provided within this application is true and valid.
I have read and understand the conditions of this application.
I acknowledge that if I fail to appear and remain at my scheduled In-Person Screening until my matter has been determined by the Screening Officer, I will be deemed to have abandoned my request for a Screening, the Administrative Penalty will be affirmed and I will be liable for an additional fee for having failed to appear ($150.00).
I have read and understand this application.

Signature:

Sign above

Date and Time of Signature

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