Required fields are marked with asterisks (*)

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 the following individual to act and appear for me as my agent in the matter pertaining to the following Penalty Notice(s)

Penalty Notice Number:

Please List Any Additional Penalty Notice Numbers (If Applicable):

Declaration

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

Signature of Registered Owner

Clear

Would you like to add another Registered Owner to this form?

Yes

Date:

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 can be directed to By-law Division, 1 Bailey Street, Port Carling, ON P0B 1J0, 705-765-3156 ext. 234, bylaw@muskokalakes.ca.