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Required fields are marked with asterisks (*)

Screening Request Form

Please fill out this form if you would like a screening request to take place.

You can submit this request online or print it off once you are finished entering in all the fields by right clicking and selecting print and mailing your request in to:

Municipal Enforcement Services
1st Floor, Waterloo City Hall
100 Regina St. S.
Waterloo, ON
N2J 4A8

Please provide registered owner's name

Please provide registered owner's address, including postal code

Please provide the registered owner's telephone number

Please provide registered owner's email address

Is the applicant's information different from the owner?

Yes

Please note: if you are not the owner of the vehicle, a screening request will only be processed if you have submitted an authorization to act as agent form.

Please provide the penalty notice number

Please provide the date the penalty notice was issued

Please provide the infraction description from the penalty notice

Please upload a copy of your penalty notice

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Please indicate why you have made the above requests.

Please contact the city at 519-747-8785 or amps@waterloo.ca if you require accessibility accommodation.

Please acknowledge that all screening reviews will be in English and if you require an interpreter, you are responsible for providing your own.

I am comfortable speaking English.

I will be bringing an interpreter.

Declaration

I certify that all information provided in this application is true and accurate. I will notify the city if any of the information changes before the hearing date.

Declaration and authorized signature

Clear

To the extent that the following information constitutes personal information as defined in the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990, chapter M.56 as amended, the information is subject to provisions of that Act and will be used for the purposes indicated or implied by this form. Questions about the collection of personal information should be directed to the City Clerk, Waterloo City Centre, 100 Regina Street South, Waterloo, Ontario, N2J 4A8, telephone (519) 886-1550.

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