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Authorization To Act As Agent

Complete this form if you are authorizing someone else to act on your behalf in relation to a Penalty Notice. I/we, the undersigned, am the registered owner(s) of the vehicle bearing Plate Number:

I/we hereby authorize the following person to act and appear for me as my agent in the matters pertaining to the following Penalty Notice(s):

Agent's First Name

Agent's Last Name

Penalty notice number

Penalty notice issued on

Vehicle Licence Plate Number

Registered Owners First Name

Registered Owners Last Name

Street Address

Town/City

Province

Postal Code

Phone Number

Email Address

I/we authorize the agent to act on my behalf in relation to the above Penalty Notice(s) and to enter an agreement to any penalty or resolution the agent deems appropriate toward a conclusion of this matter.

I/we am aware that if there is an administrative penalty and/or administrative fees to be paid after the Screening Review or Hearing Review, the ultimate responsibility to pay these amounts rests with me.

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