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Authorization to Act as an Agent - AMPS

Complete this form if you are authorizing a person to act on your behalf during a Screening Review or Hearing Appeal appointment.

Your Name

Authorized Person's Name

I hereby authorize the person identified above to act and appear for me as my agent in the matter pertaining to Penalty Notice(s):

Penalty Notice Number

They may enter a plea to any infraction he or she deems fit towards completion of these matters as authorized by me in writing. I am aware that if there is a financial penalty to be paid after the Screening Review or Hearing Appeal appearance, the ultimate responsibility to pay the penalty or penalties rests with me.

Signature

Clear

Date

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