Missing header image
* Denotes that the field is mandatory.
Health Infringement Appeal
This form is a legal document and can be used as evidence in Court.
Contact Details
Full name and address details must be provided or this appeal will not be accepted.

Please do not enter any credit card information in this form. If further information is required, an authorised City of Perth Officer will contact you.
First Name *
Surname *
I am the *
Postal Address *
Suburb *
Postcode *
Phone Number *
Mobile Phone Number
Contact e-mail address *
Appeal
Infringement Number *
Infringement Date *
Calendar
City of Perth Permit Number
(If applicable)
Reason for appeal *
Evidence to support Appeal
If you have evidence to support
your appeal, attach here
Delete File
Attachment Description
(eg. Licensee Details
If you have evidence to support
your appeal, attach here
Delete File
Attachment Description
(eg. Other supporting documents)