Online Form - Appeal an Infringement

To successfully appeal your infringement, you will be required to submit evidence to prove that an Authorised Officer has made a mistake.

Infringements are designed to point out the seriousness of your failure to act responsibly. Whether you have been caught parking in an ACROD bay without the appropriate certification, or if your firebreaks have failed inspection, it is your civic duty to act more responsibly in future.

Before you submit your appeal, please first read the detail about common infringements in the Shire of Denmark available at the links below:

Firebreak and Fuel Management Notice Infringement FAQs Using Your ACROD Permit

Instructions

Please complete the following form with as many details as you can to help us process your request in a timely manner.

This form is only to be used for non-urgent requests, for any urgent or dangerous issues, please call the Shire of Denmark on (08) 9848 0300

Please note that we take your privacy seriously and will not disclose your details to any third party without prior permission.

Contact Details

Title

Given Names*

Last Name*

Company Name

Contact Phone Number*

Email Address:*

Residential Address*

Postal Address (if different from residential)

What is your preferred method of receiving correspondence

EmailPostTelephone

Infringement Details

Infringement Number (required)*

Date of Infringement (required)*

Provide a reason for your appeal*

Attachment 1