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New Customer Service Request

Edit non submitted Customer Request

* Denotes that the field is mandatory.

Local Law Infringement Nomination

This form is a legal document and can be used as evidence in Court.

Nomination Details

Full name and address details must be provided or this nomination will not be accepted.

I (first name or given name) *

Surname *

Postal address *

Suburb *

Postcode *

Phone Number *

Mobile Phone

Contact email address *

Hereby state that the person/organisation responsible for:

Infringement number *

issued on: (date of infringement) *

is: (Full name or Organisation) *

Address (of nominated) *

Suburb (of nominated) *

Postcode (of nominated) *

Evidence to support Nomination

Information to support nomination

Describe Attachment eg. work contract

If you have evidence to support your nomination, attach here