Nomination Statement Form

Privacy Statement

The personal information is being collected by Council to assess the ‘Nomination Statement’ of your infringement notice(s), under the Infringements Act 2006.  The information will be stored in Council’s Customer Database and used to identify you when communicating with Council and for the delivery of services and information.  Your information may need to be verified by VicRoads and disclosed as permitted by law or enforcement purposes.  For further information on how your personal information is handled, view our Privacy Policy here.

Owner of Vehicle Details
Preferred Contact Number Type (required)
Preferred method of contact (required)
I declare that:
Details of the person or corporation who was in possession or control of the vehicle at the time of the offence

Please Note: Nominating a person who resides outside of Australia cannot be accepted by Council. Should the person who was in control of the motor vehicle at the time of the offence reside outside of Australia, owner onus applies and therefore you are liable for the infringement.

Details of the person or corporation who was in possession or control of the vehicle at the time of the offence

Please Note: Nominating a person who resides outside of Australia cannot be accepted by Council. Should the person who was in control of the motor vehicle at the time of the offence reside outside of Australia, owner onus applies and therefore you are liable for the infringement.

One file only.
64 MB limit.
Allowed types: txt rtf pdf doc docx odt ppt pptx odp xls xlsx ods.
One file only.
64 MB limit.
Allowed types: pdf doc docx jpg png.
Request a Court Hearing
Confirmation the details provided are correct and sign to complete nomination statement

Confirm the details provided are correct and sign to complete nomination statement:

It is an offence under the Road Safety Act 1986 (which may carry a fine in excess of $9,000 and potential licence loss for an individual, or a fine in excess of $18,000 for a body corporate) to knowingly provide false or misleading information in a nomination statement. I understand that I may be served with a summons to give evidence in relation to this nomination.

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