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Request for Hearing Review

Applicants are responsible for the completion and accuracy of this form.

Please Note: your penalty notice must have been reviewed by a screening officer prior to submitting this request

Penalty Notice Recipient

Name (first and last)

Address

City/Town

Province

Postal Code

Confirm Email

Phone (Main)

Penalty Notice Information (Ticket Information)

Penalty Notice#

Penalty Date(mm/dd/yyyy)

Plate Number, Name or Company Name

Reason for Review (you are required to provide specific reason(s))

Please provide a factual and detailed explanation of your reason(s) for your request.
If you wish to support your request with images or other documents, please attach them to this request.

Attachment(s) included:

Yes

Upload supporting documents or images:

Language Requirements

All hearings will be held in English. The City of Cambridge does not provide interpreters. You are responsible for providing your own. An interpreter can be a friend, neighbour, or relative.

If you require assistance with obtaining language support, please contact YMCA Immigrant Service at 519-621-1621 or email newcomers@ytr.ymca.ca. You can also contact the KW Multicultural Centre at 519-745-2531 or email home@kwmulticultural.ca.

Accessibility Accommodation

Accessibility Required

The City of Cambridge is committed to providing accessible and inclusive services and facilities as required in the Ontario Human Rights Code and the Accessibility for Ontarians with Disabilities Act. If you require an accommodation to be able to fully participate in any part of the hearing process, please contact us by email at accessibility@cambridge.ca or by phone at 519-623-1340 extension 4292.

Statement of Penalty Notice Recipient

I represent and warrant that:

I am the registered owner of the vehicle AND/OR the person named on the Penalty Notice.

My penalty notice been reviewed by a screening officer

I acknowledge that if I or my authorized representative fail to appear and to remain at my scheduled hearing until my matter has been determined by the Hearing Officer, I will be deemed to have abandoned my request for a hearing, The Penalty Notice will be affirmed, and I will be liable for any additional administrative fees and a $50 no-show fee

I have read and understood the conditions of this application

Signature

Signature Date

The personal information on this form is collected under the authority of the Municipal Act, 2001 and will be used in the administration of the Administrative Penalty System. Questions about this collection should be directed to the Manager of Municipal By-law Compliance, City of Cambridge, 50 Dickson Street, Cambridge, ON N1R 5W8; Telephone 519-623-1340 Ext. 7907 or email bylaw@cambridge.ca