ASE Administrative Penalty

Authorization to Act as an Agent Form

All mandatory fields are marked with an asterisk (*).

Name of Registered Owner of Vehicle

Email Address

Please provide your phone number in the event that we need to reach you

What date is your review scheduled to take place?

How many Penalty Orders are being reviewed?

1

2

3

4

Please list all Penalty Orders that are being heard in your review

What is the reason for your appeal?

Financial Hardship

Vehicle/Plates were stolen

Medical Emergency

Other

I hereby authorize the following individual to act and appear for me as my representative in the matter pertaining to the above-noted penalty order(s) issued under Essa's ASE Program:

Is the agent a Paralegal/Lawyer?

No

Yes

I am aware that if there is a fine to be paid after the Screening/Hearing appearance, the ultimate responsibility to pay the fine(s) rests with the registered owner of the vehicle, in accordance with Section 5 of Ontario Regulation 355/22 made under the Highway Traffic Act.

Signature of Registered Owner of Vehicle

Clear

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