Required fields are marked with asterisks (*)

Authorization to Act as Agent

You must complete this form if you are authorizing a person to act on your behalf in relation to a Screening Review and/or Hearing Review. This form must be completed prior to the appointment.

Penalty Notice Recipient

First Name

Last Name

Penalty Notice Number

Penalty Notice Date

I hereby authorize the Agent listed on this form to act on my behalf at a Screening Review and/or Hearing Review pertaining to the Penalty Notice listed on this form.

I understand that if there is a penalty to be paid after the Screening Review and/or Hearing Review, the ultimate responsibility to pay the penalty rests with me.

Agent Information

First Name

Last Name

Telephone Number

Email Address

Statement - Online Form Submission

By submitting this online form to the Municipality, the user acknowledges that the submission is deemed to be a substitute for the user's signature on the online form and signifies that the user has read, understood and agreed to the terms and conditions of the online form and any document referenced in the online form.

Please confirm that you have read and accept the "Statement - Online Form Submission"

Yes, I have read and accept the "Statement - Online Form Submission"

Privacy Statement: Personal information on this form is collected under the authority of the Municipal Act, 2001 P.S.O. c.45, and will be used for the purpose of administering the Municipality’s Administrative Penalty System. Questions about the collection of this information can be directed to the Manager of Legislative Services/Clerk, Municipality of Leamington, 111 Erie Street North, Leamington, N8H 2Z9, Telephone: 519-326-5761.

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