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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

First Name:

Last Name:

Telephone Number:

Alternate Number:

Email:

Confirm email:

Mailing Address:

Unit/Apt (optional):

City/Town:

Postal Code:

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.

Does the Applicant wish to authorize a representative to act on their behalf for this Screening?

Yes

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, 50 Centre Street South, Oshawa, Ontario, L1H 3Z7, 905-436-3311.

Penalty Notice Information (Infraction)

Please provide the information found on the Penalty Notice.

Penalty Notice Number:

Penalty Date (m/d/yyyy):

Licence Plate (no spaces) or VIN:

Location where infraction occurred (at or near):