Required fields are marked with asterisks (*)

Request for Disclosure Form

Instructions:
You must provide the information on this form in order for your request to be processed. If you require assistance in completing this form, call the Town of Milton during regular business hours at 905-878-7252 #2530. Send the completed form by email, or drop it off in person at Town Hall.

Email: screening@milton.ca

Drop off Location: Town of Milton, Town Hall 150 Mary Street, Milton On, L9T 6Z5

Please note: A Request for Disclosure must be received by the Town at least 10 business days prior
to your scheduled Screening or Hearing Review appointment. It is your responsibility to follow-up on the status of your request.

Registered Owner’s Information

Last Name

First Name:

Requestor’s Contact Information

Last Name

First Name:

Email Address:

Phone number:

Fax number:

* You will be notified by e-mail or by phone when the documents are ready.

Penalty Notice Information

Penalty Notice Numbers(s):

Offence Date(s)

Screening/Hearing Date

Request type:(Circle)

Electronic

Physical

Requestor’s Signature

Clear

Date Requested