Request for Screening

Email: amps@cobourg.ca Phone: 905-372-8380
Town of Cobourg, Legislative Services
Municipal Law Enforcement & Licensing Services
55 King Street West Cobourg, ON K9A 2M2

Applicants are responsible for the completion and content of this form.

*Required

Penalty Notice Information (Infraction) (Please provide the information found on the Penalty Notice)

Reason for Screening* (you are required to provide specific reason(s))

• Please provide a factual and detailed explanation of your reason(s) for your Screening request.
• If you wish to support your Screening with images or other documentation please bring them with you at your scheduled In-Person Screening (if applicable) or attach them to this request.
• The Screening Decision will be sent to you by mail or email, if provided

Statement of Penalty Notice Recipient

I represent and warrant that:

• I am the registered owner of the vehicle (for Parking Penalty Notices only); or
• I am the person named on the Penalty Notice (for Non-Parking Penalty Notices only);
• I acknowledge that if I fail to appear and to remain at my scheduled In-Person Screening until my matter has been determined by the Screening Officer, I will be deemed to have abandoned my request for a Screening, the Administrative Penalty will be affirmed, and I will be liable for an additional fee for having failed to appear (currently $50.00), and
• I have read and understand the conditions of this application

Personal information contained on this form is collected and will be used for the purpose of administering the Town’s Administrative Penalty process. Questions about this collection  should be directed to the Town of Cobourg’s Freedom of Information Co-ordinator at 905-372-4301.