Request for Screening

Applicants or their Authorized Representative are responsible for the completion and content of this form.

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Penalty Notice Recipient

Authorized Representative:

If the Applicant wishes to have an Authorized Representative, please list their information below. A completed Administrative Penalty Authorization of Representative form MUST be signed by the Applicant (registered vehicle owner or person named on the penalty) and submitted to the City in order for the Authorized Representative to take any action on the Applicant’s behalf. Only certain individuals may be an Authorized Representative – please see the form for more details.

This form may contain personal information as defined under the Municipal Freedom of Information and Protection of Privacy Act. This information is collected under the legal authority of the Municipal Act, 2001, S.O. 2001 c.25, as amended. This information will be used and maintained by the City of Oshawa for the purpose of administering the City’s Administrative Penalty process. Questions regarding this collection may be directed to the City’s Information Access and Privacy Officer, City of Oshawa, at 905-436-3311.

Penalty Notice Information (Infraction)

Please provide the information found on the Penalty Notice.

Please note: A separate Request for Screening form must be completed for each penalty notice you wish to dispute.