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Authorization to act as Agent

Please submit this form to authorize a person to act on the behalf of the Registered Owner of the vehicle named on the Parking Penalty Notice at a Screening and/or Hearing Review.

I, the undersigned, am the registered owner(s) of the vehicle bearing Plate No.:

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

Penalty Notice Number:

Date penalty notice issued on:

Registered Owner(s) Address;

Registered Owner(s) Telephone Number;

I authorize the agent to act on my behalf in relation to the above Penalty Notice(s) and to consent to the decision made by the Screening or Hearing Officer. I am aware that the ultimate responsibility to pay the Administrative Penalty rests with me and that the Screening or Hearing Decision will be provided to the named agent on this form.

Registered Owner 1

Name:

Date:

Signature

Clear

Registered Owner 2

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.