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Form Builder

Required fields are marked with asterisks (*)

Welcome

If you have received a Penalty Notice and believe you did not commit the offence as indicated, you can complete this form to have it reviewed by a Screening Officer.

Penalty Notice Recipient

Penalty Notice Information (Infraction)

Please provide the information found on the Penalty Notice

Type of Screening Requested

You are required to select one preferred method of Screening.

Please note: A Written Screening allows your Screening to be processed without your attendance.

Scheduled Screenings will be booked for the next available business day. Your time preference will be considered but cannot be guaranteed. A notice will be sent to you confirming the date and time of your Screening appointment. Telephone and electronic Screening appointments cannot be rescheduled or adjourned. 

Reason for Screening

You are required to provide specific reason(s). If you wish to support your Screening with images or other documentation, you will have an opportunity to attach them to this request.

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Statement of Penalty Notice Recipient

By signing below, 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 attend and to remain at my scheduled telephone or electronic meeting 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 attend ($50.00), and
  • I have read and understand the conditions of this application.
Clear


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A-Z Services:
Township of Wainfleet footer logo

31940 Highway #3
PO Box 40
Wainfleet, ON L0S 1V0

Phone: 905-899-3463
Fax: 905-899-2340

After-Hours Urgent Contact
Region of Niagara Central Dispatch
Phone: 905-984-3690

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