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Infringement Appeal Form

Application to Appeal an Infringement as per the Fines, Penalties and Infringement Notices Enforcement Act 1994.

Given Name/s*

Surname*

Postal Address

Street Address:

City:

State:

Post Code:

Country:

Email Address*

Phone Number*

Date of Birth*

License Number*

Vehicle Registration*

Infringement Number*

Date of Issue*

Reason for Appeal (please check)*

Medical emergency - documentation is required from your medical professional
Mechanical emergency - documentation is required from reputable motor service company
Infringement was issued contrary to the law
Other, please provide details below.

Please provide details

Upload documentation if applicable

Max File Size: 10.00 MB
Allowed File Types: .avi, .doc, .docx, .gif, .jpeg, .jpg, .mov, .mp3, .mp4, .mpeg, .mpg, .pdf, .png, .ppt, .pptx, .xls, .xlsx

Declaration*

Date of Declaration*

Welcome to the Shire of Exmouth

Infringement Appeal Form

General Office:

Address