Required fields are marked with asterisks (*)

Authorization to act as an Agent for an Individual

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

Name of Registered Owner of vehicle:

Registered Owner Email:

Registered Owner Telephone Number:

How many Penalty Orders are being reviewed?

Please list all Penalty Orders that are being heard in your review:

I hereby authorize the following individual to act and appear for me as my representative in the matter pertaining to the above-noted penalty order(s) issued under the County of Brant's Automated Speed Enforcement program:

Is the agent a Paralegal/Lawyer?

Yes

By checking this box, I confirm I

am aware that if there is a fine to be paid after the Screening/Hearing Review, the ultimate responsibility to pay the fine(s) rests with the Registered Owner of the vehicle, in accordance with Section 5 of Ontario Regulation 355/22 made under the Highway Traffic Act.

understand the personal information on this form is collected in accordance with the Municipal Act, 2001 and the Highway Traffic Act, R.S.O. 1990, c. H.B. and will be used for the purpose of administering the Automated Speed Enforcement program. Questions regarding the collection of this information may be directed to the County of Brant Record Services at 519.442.7268 x 2220

Signature of Registered Owner:

Clear

Today's Date: