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Personal Details

First Name *

Last Name *

Company

Daytime Contact Number *

Residential address *

Postcode *

Postal address same as residential *

Yes

Date of birth *

Email Address *

Suburb *

Postal address *

Postal Postcode *

Suburb *

Infringement Details

Infringement Number *

Vehicle Registration *

I declare that I was not in possession of control of the vehicle at the time of the alleged offence. *

Someone else was the driver

Vehicle sold prior to offence

Vehicle stolen or plates stolen

Infringement Date *

Nominated first name *

Nominated daytime contact number *

Nominated suburb *

Nominated last name *

Nominated residential address *

Nominated Postcode *

Date sold *

Vehicle transfer papers *

Police report number *

Declaration

It is an offence under Section 9.11 of the Local Government Act 1995 to provide false or misleading information. I acknowledge that I understand that providing false or misleading information is an offence. *

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