Court hearing request form

Only the person named on the original notice or an authorised representative of the individual, company or incorporated body named on the original notice can request a Court Hearing.

If you are requesting a court hearing on behalf of the person named on the original notice, then you must fill out a "Pro-Forma - Authority to act on my behalf for the purposes relating to my Infringement Notice(s)" form. This form can be found on the Police website (PDF 47KB).

(Please note: Police cannot action a Court Hearing request for any notice that has either been paid or transferred to the Fines Collection Unit of the Ministry of Justice. The option of payment to the Police is no longer available once a Court Hearing has been processed.)

Police Notice Number

ICN

(Safety Camera Reference Only)

Name on Notice

First Name(s)

Surname

Date of Birth

Postal or street address

Suburb

City

Postcode

Company name

This is the address that I would like my disclosure sent to

I confirm I am authorised to act on the individual or Company’s behalf in requesting a Court Hearing

Choose one that applies to your request

I confirm I am the individual named on the Notice and I wish to request a Court Hearing

I confirm I am authorised to act on the individual or Company’s behalf in requesting a Court Hearing

If you are submitting this Court Hearing Request form on behalf of the entity named on the Notice, please upload and submit a Pro-Forma Form.
You can find a Pro Forma - Authority to Act Form on the Police website.

Upload completed Pro-Forma form

One file only.
5 MB limit.
Allowed types: pdf, doc, docx, jpg, jpeg, jfif, .

I request a Court Hearing for

All offences on the notice OR

List the offence(s) on the notice

AND I wish to

I wish to plead not guilty and request a defended Court Hearing OR

I wish to admit liability for the offence(s) and provide submissions for consideration by the Court

Provide supporting information

Option 1: type the details below

Option 2: upload a document

One file only.
10 MB limit.
Allowed types: gif, jpg, jpeg, jfif, png, txt, pdf, doc, docx.

Full Name of Requester

Name

Date

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