Required fields are marked with asterisks (*)

AMPS - Authorization to act as an agent

Complete this form if you are authorizing a person to act on your behalf during a Screening Review or Hearing Review appointment. The authorized person should bring this completed form with them.

Agent information

Provide the first and last name of the person you want to authorize to act on your behalf.

First name

Last name

Penalty notice information

Please provide the penalty notice number(s) below.

Penalty notice number 1

Penalty notice number 2

Penalty notice number 3

Penalty notice number 4

Authorization

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

Penalty Notice Number(s):

My authorized agent may enter a plea to any penalty he or she deems appropriate toward a conclusion of this matter.

I am aware that if there is a fine to be paid after the Screening Review or Hearing Review, the ultimate responsibility to pay the fine(s) rests with me.

Your contact information

Please fill the fields out below for yourself.

First name

Last name

Phone number

Email address

Signature

Clear

Note: This form must be printed, signed and brought to the Screening and Hearing Review appointment by the agent named on the form.

The personal information on this form is collected in accordance with the Municipal Act, 2001 and will be used in the administration of the Administrative Monetary Penalty System.

Questions about this collection of information can be directed to By-law enforcement staff at telephone number 519-741-2345 or email to ian.misheal@kitchener.ca.