* 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)

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

I Agree And Wish To Continue