Screening Review Application

All requests for review must include a factual and detailed explanation of the reasons for your request. If you wish to support your screening review request with images or other documents, please include them with this application form. Candidates are responsible for the completion and content of this form. For more information on SAP, visit www.hawkesbury.ca

Name (First and Last Name)

Home Phone Number

Address

Cell Number

Municipality

Province

Postal Code

Email Address

Penalty Notice Number

Penalty Offence Date

Plate Number or Name on the Penalty Notice

Location where the infraction occured

complete for non-parking Penalty Notices only

Offence listed on penalty notice

Section Number

Reason For Screening

(please provide specific reasons) Please provide a factual and detailed explanation of your reasons for requesting a review. - If you would like to support your request for review with images or other materials, please bring them to your scheduled in-person review or attach them to this request.

Documents, photos or other documents supporting your request for review

Drag and drop files here or click to upload

Insert original penalty notice

Please insert a photo or a scanned copy of your original penlaty notice.

I represent and certify that:

Consent Form

Your signature

Date of signature

Please indicate your desired date and time of appointment for the examination below. (Please choose at least 2 time slots) When considering your availabilities, please consider that request times are always schedule the following week of your request. No same week request are offered.

Your preference date and time will be taken into account, but cannot be guaranteed.

If you submit your request through this form, a notification will be sent to you. Date and time will be confirmed by an agent by phone.

In-person exam appointments cannot be canceled or postponed.

If you do not show up for your exam appointment, an additional administrative fee will be added to the penalty amount.

The personal information contained in this form is collected and will be used for the purpose of administering the City's administrative penalty process. Questions regarding this collection of personal data should be directed to the Town of Hawkesbury at 613-632-0106 or sent by email to: infobylaw@hawkesbury.ca

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Screening Review Application