Required fields are marked with asterisks (*)

Authorization

Please submit this form to authorize an individual to act on the behalf of the Person named on the Penalty Notice(s) at a Screening and/or Hearing Review.

I hereby authorize the following Person to act and appear on my behalf as my agent in all matters pertaining to the relevant Penalty Notice(s):

Penalty Notice Number:

Date penalty notice issued on:

Person named on Penalty Notice(s) Address:

Person named on Penalty Notice Telephone Number:

I, the undersigned, am the Person named on the relevant Penalty Notice(s). I understand that ultimate responsibility for payment of the Administrative Penalty rests with me, and that the Screening and/or Hearing decision will be provided to the agent named on this form:

Name:

Date:

Signature

Clear

Any personal information as defined in the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990, as amended, is subject to provisions of that Act and will be used for the purposes indicated or implied by this form. Questions about the collection of personal information should be directed to the County of Brant, call 519.44BRANT (519.442.7268) or toll free 1.855.44BRANT or info@brant.ca.