Request a Hearing Form

Plate / VIN (If your Penalty Notice is WHITE please N/A)(Required)

Penalty Notice #(Required)

Date of Screening Decision(Required)

Name(Required)

First Last

Email(Required)

Phone

Are you the registered owner of the vehicle or have their permission to submit on their behalf?(Required)

Yes

No - The owner of the vehicle or a person with authority of the owner is required for the Town to review the request.

Not applicable (select this option if the offence is not related to parking)

Which time of day would you prefer for your appointment? (one must be selected)(Required)

Morning (9 a.m. to 12:20 p.m.)

Afternoon (12:30 p.m. to 4 p.m.)

Please provide the reason(s) you disagree with the decision of the Screening Officer.

Except for any documents submitted for your Screening, do you have any additional documents to submit? (maximum of 2)

Drop files here or

Max. file size: 10 MB, Max. files: 2.

Collection of Personal Information

Collection of Personal Information Personal information contained on this form is collected pursuant to the Municipal Act, 2001, s. 11(1), and will be used for the purpose of "Requesting a Hearing". Questions about this collection should be directed to the Records & Freedom of Information Coordinator at 65 Harwood Avenue South, Ajax, Ontario, L1S 2H9 or 905-683-4550 Accessibility This form is available in alternate formats, upon request, by contacting 905-683-4550, or email accessibility@ajax.ca