AMPS Authorization Form - Township of Oro-Medonte

Required fields are marked with asterisks (*)

Administrative Monetary Penalty System (AMPS) Authorization Form

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.

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:

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 rests with me.

Name of Registered Owner:

I consent to authorize.

Yes

Date:

Name of Registered Owner:

I consent to authorize.

Yes

Date:

Personal information contained in this form is collected under the authority of the Municipal Act, S.O. 2001, c.25, as amended and will be used to process the applicant’s Request for Review of the Screening Officer. Questions about this collection can be directed to the By-law Division, 148 Line 7 South, Oro-Medonte, ON L0L 2E0, 705-487-2171, municipallaw@oro-medonte.ca.