Fillable Traffic infringement (not including parking) ive unregistered in (Department of Infrastructure, Transport, Cities and Regional Development)

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Traffic infringement (not including parking) ive unregistered in (Department of Infrastructure, Transport, Cities and Regional Development)

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Country of origin: AUSTRALIA
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Case Reference:
First Name:
Surname:
Address:
Phone:
Note: Complete only if the infringement is in the name of a company*
Company
address:
Postcode
Position held in company
* ONLY THE PERSON NAMED ON THE INFRINGEMENT NOTICE CAN APPLY OR IF THE INFRINGEMENT IS ISSUED AGAINST A COMPANY, A PERSON AUTHORISED BY THAT
COMPANY. ANY PERSON MAKING AN APPLICATION ON BEHALF OF A COMPANY MUST HAVE A LETTER OF AUTHORITY TO ACT SIGNED BY THE COMPANY DIRECTOR
ACCOMPANYING THEIR APPLICATION, WHICH MUST BE FILED WITH THE REGISTRAR PRIOR TO THE HEARING DATE.
Respondent
Company Name:
1. DETAILS OF PERSON MAKING THE APPLICATION
2. INFRINGEMENT NUMBERS:
APPLICATION FOR EXTENSION OF INFRINGEMENT – 28 days to deal with infringement notice
•
Traffic infringement (not including parking)
•
Dr
ive unregistered in a toll zone (Eastlink, Melbourne City Link)
Victoria Police/Traffic Camera Office
Case reference:
Postcode:
I hereby make application pursuant to
For an extension of time of 28 days to deal with the infringement.
I first became aware of this/these infringements on (date):
I, of [address] ,
make the following statutory declaration under the
Oaths and Affirmations Act 2018
:
I declare that the contents of this statutory declaration are true and correct, and I make it knowing that making a statutory
declaration that I know to be untrue is an offence.
Applicants signature ,
Declared at ,
in the state of Victoria ,
o
n .
I am an authorised statutory declaration witness
i
and I sign this document in the presence of the person making the
declaration:
Witness name
, Qualification
Before (signature of witness) Address:
i
A person authorised under section 30(2) of the Oaths and Affirmations Act 2018 to witness the signing of a statutory declaration.
LISTING OF APPLICATION
(registrar to complete)
This application is listed for hearing before the Magistrates’
Court at
at am / pm on (date)
Date:
Registrar of the Magistrates’ Court
3. TO THE COURT
4. GROUNDS FOR MAKING THE APPLICATION
Please choose one
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Traffic infringement (not including parking) ive unregistered in (Department of Infrastructure, Transport, Cities and Regional Development)

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Completed 31 August 2021

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