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. I have read and understood the Privacy Statement mentioned above (required) Infringement No (required) Vehicle Registration Number Owner of Vehicle Details Title - None -MissMsMrMrsDr Given Name (required) Family/Surname (required) Preferred Contact Number?(required) Preferred Contact Number Type (required) Home Work Mobile Corporation name and ACN (if applicable)? Street/Road Number?(required) Street/Road Name (required) Suburb (required) Post Code (required) Email Preferred method of contact (required) Email Post I declare that: Someone else was the driver in possession or control of the vehicle at the time of the offence I sold this vehicle to someone else or permanently disposed of the vehicle on this date I believe the vehicle or number plates displayed on the vehicle were stolen. (Note: You must attach Police Report) I was incorrectly nominated as the responsible person in relation to the vehicle and I reject the nomination. I request a Court Hearing 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. Surname/Corporation Name? First Name / Corporation ACN Street/Road Number ? Street/Road Name Suburb Post Code Drivers License / Permit Number State / Country of Issue Date of Birth 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. Surname/Corporation Name? First Name / Corporation ACN Street/Road Number? Street/Road Name Suburb Post Code Drivers License / Permit Number State / Country of Issue Date of Birth Upload a copy of vehicle transfer or documentation from VicRoads to verify they sold the vehicle One file only.64 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Tell us what reasonable and diligent enquiries you’ve made to try to identify the person in possession or control of the vehicle at the time of the offence, or why you are rejecting the nomination.? Upload Police Report One file only.64 MB limit.Allowed types: pdf, doc, docx, jpg, png. Request a Court Hearing Full Name Your Drivers License Corporation name and ACN (if applicable) Date of Birth Street/Road Number? Street/Road Name Suburb Post Code Mobile No I decline to have this matter dealt with under these enforcement provisions and want to have the matter heard and determined by a Court. I understand I may receive a summons for this offence. 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. Signature (required)Sign above Date (required)