Required fields are marked with asterisks (*)

Request for Screening

Please complete this form to request a Screening.

Personal information contained on this form is collected and will be used for the purpose of administering the Township’s Administrative Penalty process. Questions about this collection should be directed to the Township of West Lincoln’s Freedom of Information Officer at 905-957-3346.

Penalty Notice Recipient

Name (first and last)

Home Telephone

Other Telephone

Fax Number

Address

City

Province

Postal Code

Email Address

Penalty Notice Information (Infraction)

Please provide the information found on the Penalty Notice

Penalty Notice No.

Penalty Date

Plate Number OR Name on Penalty Notice

Location where the Infraction occured (complete for non-parking Penalty Notices only)

Offence

Section Number

Screening Information

Type of Screening Requested

Written Screening (allows your Screening to be processed without your attendance at the Township Municipal Office)

In-Person or Remote Screening (Screening at Township Municipal Office, attended in-person or virtually) - In-Person Screening appointments cannot be rescheduled or adjourned

Reason for Screening - You are required to provide specific reason(s). Please provide a factual and detailed explanation of your reason(s) for your Screening request.

If you wish to support your Screening with images or other documentation, please attach your files. The Screening Decision will be sent to you.

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Statement of Penalty Notice Recipient

I represent and warrant that:

I am the registered owner of the vehicle (for Parking Penalty Notices only); or

I am the person named on the Penalty Notice (for non-Parking Penalty Notices only).

I represent and warrant that:

I acknowledge that if I fail to appear and to remain at my scheduled In-Person Screening until my matter has been determined by the Screening Officer, I will be deemed to have abandoned my request for a Screening, the Administrative Penalty will be affirmed, and I will be liable for an additional fee for having failed to appear ($50.00 for parking or $100.00 for non-parking).

I represent and warrant that:

I acknowledge that this ticket remains in effect and that it is my responsibility to ensure that I have received the decision from the Screening Officer.

I represent and warrant that:

I acknowledge that all time constraints stipulated within By-law 2014-67, as amended, are still in effect.

I have read and understand the conditions of this application. (Signature)

Clear