Required fields are marked with asterisks (*)

Request for Screening

Applicants are responsible for the completion of and accuracy of the information provided on this form.

Page 1 of 4

Penalty Notice Recipient

First Name:

Last Name:

Telephone Number:

Alternate Number:

Email:

Mailing Address:

City/Town:

Province:

Postal Code:

Personal information on this form is collected pursuant to Section 11 of the Municipal Act, 2001 and will be used for the purpose of administering the City’s Administrative Penalty process. Questions about this collection should be directed to the City of Oshawa’s Information, Access and Privacy Officer at 50 Centre Street South, Oshawa, Ontario, L1H 3Z7 or by phone at 905-436-3311.

Penalty Notice Information (Infraction)

Please provide the information found on the Penalty Notice.

Penalty Notice Number:

Penalty Date (m/d/yyyy):

ByLaw Number

Location where infraction occurred (at or near):

Request for Screening

Page 1 of 4

Penalty Notice Recipient

Penalty Notice Information (Infraction)

Contact