Notice of Election for a Court Hearing

To have the offences set out in your infringement notice heard and determined by a court you must complete and return this ‘Notice to Elect a Court Hearing’ to the Monetary Penalties Enforcement Service within 28 days of being served with the infringement notice.

Note

• Print clearly in the boxed spaces;
• Provide an Australian residential address. PO boxes cannot be accepted;
• Send your completed form to the Monetary Penalties Enforcement Service.

I understand that once I submit this form

• I will be served with a summons to attend court;
• I will not be able to pay this infringement notice; and
• If the issuing authority decides not to prosecute it will notify me of that decision.

Information

Name *

Date of birth *

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Street number and address

Suburb

State

Postcode

Phone no.

Mobile no.

Email address

Declaration

Full name *

Date *

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The following information is to be completed by organisations only

Identification number (eg. ACN)

Full name of person completing for (duly authorised to sign on behalf of the organisation)

Position

Personal information collected from you will be used by the Monetary Penalties Enforcement Service for determining this application. Failure to provide this information may result in your application not being able to be processed. Your personal information will be used for the primary purpose for which it is collected, and may be disclosed to contractors and agents of the Monetary Penalties Enforcement Service, law enforcement agencies, courts and other organisations authorised to collect it. Your basic personal information may be disclosed to other public sector bodies where necessary for the efficient storage and use of the information. Personal information will be managed in accordance with the Personal Information Protection Act 2004 and may be accessed by the individual to whom it relates on request to the Monetary Penalties Enforcement Service. You may be charged a fee for this service.