* Denotes that the field is mandatory.

Please provide the infringement number and vehicle registration
Infringement Number *
Vehicle Registration *
Please provide your name and address details
Full Name or Corporation Name *
Postal Address *
Your Email Address (For Confirmation Email)
List the details of the person or corporation who was in possession or control of the vehicle at the time of the offence.

Note: This statement will be rejected if you do not provide a drivers licence number or date of birth for a nominated individual or an ACN for a nominated corporation. If the vehicle is a taxi-cab, you must provide the driver’s accreditation number.

Full Name or Corporation Name *
ACN Number (if applicable)
Postal Address *
Date of Birth (if applicable)
Calendar
Drivers Licence Number (if applicable)
Taxi DC Number (if applicable)
Contact Email Address
I state that I was not driving or in possession or control of the vehicle at the time of the offence.

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