Infringement - Application for Internal Review

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Applicant Details

Who is applying (confirm who is making the application)

Person named on the infringementOther person with consentAuthorised company representative

Full Name *

Corporate Name and ACN (if applicable)

Preferred method of contact (outcome will be sent here) *

MailEmail

Address of person/ Corporate *

Street address *

City *

State *

Postcode *

Email Address

Phone Number

Infringement Details

Infringement Notice Number

Vehicle Registration/ Animal Number

Grounds for application

Person unaware: you did not know about the fineContrary to law: the fine is invalid or was improperly issued to youMistake of identity: the fine was issued to the wrong personExceptional circumstances: the offence occurred due to an extraordinary or unavoidable situationSpecial circumstances: you have serious personal issues, conditions or difficulties

Explanation of circumstances and ground(s) in support of application

Attachments

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Please upload any supporting documentation

Declaration

I understand that this is the only internal review for this infringement that I am able to submit pursuant to s.22(2) of the Infringements Act 2006.
I declare that the information that I have supplied in this form and any attachments to this form, are true and correct to the best of my knowledge.
I understand that by making a false or misleading statement in support of this claim, I may be prosecuted.

Signature

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I Have read the Warrnambool CIty Council Privacy Policy