Part 1 - Expiation Notice and Recipient Details

Full Name *

Email *

Address *

Phone *

Licence Number *

State Issued *

Date of Birth *

Is this a Company Owned Vehicle? *

Yes

No

Received Expiation Notice Number *

Issued to Vehicle Registration Number *

Part 2 - Nomination

I was the owner of the abovenamed vehicle but was not the driver. To the best of my knowledge and belief, at the time of the alleged offence, the driver was:

At the time of the alleged offence, the vehicle had been:

WARNING: Under section 174A (13) of the Road Traffic Act 1961, there is a maximum penalty of $25,000 or four (4) years imprisonment for making statement that is false or misleading in a material particular, when making a nomination. You may be asked to make a statutory declaration to verify any information in this nomination.

I hereby agree that all information including my identity is true and correct

Privacy Policy *

By submitting this form, I consent to the City of Charles Sturt collecting, retaining and using my personal information provided in line with Council's Privacy Policy.

I accept this Privacy Policy *

Expiation Nomination Form

Expiation Nomination Form

Part 1 - Expiation Notice and Recipient Details

Part 2 - Nomination

Privacy Policy *