Authorization to Act as an Agent

Complete this form if you are authorizing a person to act on behalf of the registered license plate owner, or person named on the Penalty Notice during a Screening or Hearing Review appointment. This completed form must be submitted in advance of any Screening or Hearing appointment.

Requester Information

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

I understand and agree that:

• By completing this form I am consenting, and my authorized agent will act on my behalf with respect to the above noted Penalty Notices.
• My Agent may agree with any decision made by the Screening or Hearing Officer and may agree with any penalty, administrative fee or other charges assessed by the Screening or Hearing Officer.
• I remain responsible for any penalties, administration fees or other charges.
• The Screening or Hearing Review Decision will be provided to the named Agent on this form.

The completed form must be submitted at least 48-hours prior to your schedule Screening or Hearing Appointment Date and Time.

Note: Your completion of this Form acts as your signature.  Failure to submit this completed Form a minimum of 48-hours prior to your Screening or Hearing Appointment may result in your Penalty Notice being Affirmed and additional fees being added.

Personal information requested on this form is collected under the authority of section 11 of the  Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c. M.56 (Ontario)., as amended. The personal information you have provided will be used to administer and contact you regarding the above request.  Questions about this collection should be directed to the Coordinator, Administrative Monetary Penalty System and Automated Speed Enforcement at: amps@townofws.ca, 111 Sandiford Drive, Stouffville, Ontario L4A 0Z8.