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Request for Screening

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

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Penalty Notice Recipient

First Name:

Last Name:

Telephone Number:

Alternate Number:

Email:

Mailing Address:

Unit/Apt (optional):

City/Town:

Province:

Postal Code:

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):

ByLaw Number

Location where infraction occurred (at or near):