Screening Review Application

Recipient of the Penalty Notice

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 the Administrative Monetary Penalty System (AMPS) , visit www.hawkesbury.ca

First and Last Name

Recipient Phone Number (home or cellular)

Email Address

Address of the Recipient (#, road)

Municipality

Province

Postal Code

Statement of the recipient of the penalty notice.

I represent and certify that:

Fill out this form if you are a third-party agent Consent Form

About the Penalty

Section A - Parking infractions

Penalty Notice Number

Plate Number

Penalty Offence Date

Penalty Section Number

Section B - Municipal By-law Infractions

Penalty Notice Number

Penalty Offence Date

Location where the infraction occured

Offence listed on Penalty Notice

Penalty Section Number

Reason For Screening Review Request

(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.

Your signature

Date of signature

Regarding Your Review Request Appointment

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. Nosame 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 the Review Agent by phone or email. No appointment is confirmed before communication with Review Agent.

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 original penalty amount.

Please choose the desired date and time for your review. (Date and time chosen will be considered but validated by the Review Agent)

Personal information contained on this form is collected under Section 17 of the Municipal Freedom of Information and Protection of Privacy Act, and will be used to respond to your request. Questions about this collection should be directed to the Town Clerk at 600, Higginson Street Hawkesbury ON K6A 1H1, email : infogreffe@hawkesbury.ca

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