Fillable Request for Screening (City of London, Ontario)

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Request for Screening (City of London, Ontario)

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Request for Screening
screeningrequest@london.ca
Fax: 519-661-2413 Tel: 519-661-4537
824 Dundas Street, London, ON N5W 5R1
Applicants are responsible for the completion and content of this form
Please ensure areas marked with a (*) are completed and a copy of the vehicle ownership is
included with your screening
Personal Information of Penalt
y
Notice Reci
p
ient:
* Name (first and last) * Home Telephone
* Address Other Telephone
* City Fax Number (Preferred)
* Province * Postal Code Email Address (Preferred)
Information from Penalt
y
Notice:
* Penalty No. * Offence Date * Licence Plate Number
Location where Penalty Occurred
Offence Section Number
T
yp
e of Screenin
g
Re
q
uested:
(
Select one
p
referred screenin
g
method below
)
Phone Screening
Email Screening
All requests for screening must include a factual and detailed explanation of the reason(s) for your
screening request written on the next page or included as an attachment with this request form.
If you wish to support your screening request with images or other documents, please include them with
this request form.
The Screening Decision will be sent to the address/email provided on this form once a decision is made.
Personal information obtained through use of this form is collected and used for the purpose of administering legal
processes pursuant to the Municipal Act.
Form no 1830 (2021 09) www.london.ca Page 1 of 4
*Reasons for Screenin
g
Re
q
uest:
(
Write below or include attachment
*Have you included an attachment to supplement your screening request? (choose one)
Yes No
Personal information obtained through use of this form is collected and used for the purpose of administering legal
processes pursuant to the Municipal Act.
Page 2 of 4
*Statement of Penalty Notice Recipient:
I (the undersigned) am the registered owner of the vehicle bearing the number plate specified in the
penalty notice, or;
I am a third-party agent authorized in writing to act on behalf of the vehicle owner named in the penalty
notice and I will provide written authorization of such to the screening officer.
I acknowledge that if I fail to appear and remain at my scheduled screening until my matter has been
determined by the Screening Officer, I will be deemed to have abandoned my request and charged an
additional $50.00 which will be added to my penalty notice.
I have read and understand the conditions of this application.
Signature of Registered Owner of vehicle or their agent Date of signing
Instructions for Submitting Screening Request Form
Please submit your completed Screening Request Form with a copy of your ownership and additional
supporting documentation, if applicable (ie. Receipts, Permit, and/or Income Statements) to the
Municipal Law Enforcement and Parking Services Office by one of the following three methods:
1. Mail: Municipal Law Enforcement and Parking Services, P.O Box 5400, London,
ON, N6A 4L6
2. Email: screeningrequest@london.ca (must include a scanned copy of this form)
3. Facsimile (Fax): 519-661-2413
Personal information obtained through use of this form is collected and used for the purpose of administering legal
processes pursuant to the Municipal Act.
Page 3 of 4
For Internal Use Only
The following area is for City of London Staff to complete
Application Received Appointment Information
Date Stamp Appointment Date Appointment Time
Registered Owner Notified by:
Email Mail Fax In Person
Date Notified
Screening Officer Initials
Screening Decision
Screening Officer’s Signature Date of decision
Personal information obtained through use of this form is collected and used for the purpose of administering legal
processes pursuant to the Municipal Act.
Page 4 of 4
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Request for Screening (City of London, Ontario)

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Completed 13 May 2022

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