Schedule 1

Forms

In force

[r. 14]

[Heading inserted: Gazette 24 Jun 2008 p. 2831.]

Form 1

Motor Vehicle Repairers Act 2003, s. 101(1) Infringement notice		Infringement notice no.
Alleged offender	Name: Family name
	Given names
	or Company name ____________________________________ ACN
	Address _________________________________________________ Postcode
Alleged offence	Description of offence ______________________________________
	Motor Vehicle Repairers Act 2003 s. OR Motor Vehicle Repairers Regulations 2007 r.
	Date / /20 Time a.m./p.m.
	Modified penalty $
Authorised officer issuing notice	Name ______________________________________ Signature
Date	Date of notice / /20
Notice to alleged offender	It is alleged that you have committed the above offence. If you do not want to be prosecuted in court for the offence, pay the modified penalty within 28 days after the date of this notice.
	How to pay By post: Send this notice (or a copy) with a cheque or money order (made payable to the Commissioner) to: Department of Mines, Industry Regulation and Safety Consumer Protection Division Locked Bag 100 EAST PERTH WA 6892
	In person: Present this notice and your payment to the cashier at: Department of Mines, Industry Regulation and Safety Consumer Protection Division [street address to be inserted] If you do not pay the modified penalty within 28 days, you may be prosecuted or enforcement action may be taken under the Fines, Penalties and Infringement Notices Enforcement Act 1994. Under that Act, some or all of the following action may be taken — your driver’s licence may be suspended, your vehicle licence may be suspended or cancelled, you may be disqualified from holding or obtaining a driver’s licence or vehicle licence, your vehicle may be immobilised or have its number plates removed, your details may be published on a website, your earnings or bank accounts may be garnished, and your property may be seized and sold.
	If you need more time to pay the modified penalty, you can apply for an extension of time by writing to: The Commissioner Department of Mines, Industry Regulation and Safety Consumer Protection Division Locked Bag 100 EAST PERTH WA 6892 If you want this matter to be dealt with by prosecution in court, sign here _______________________________________ and, within 28 days after it was given, post this notice to the above postal address.

[Form 1 inserted: Gazette 24 Jun 2008 p. 2831-2; amended: Gazette 30 Jun 2011 p. 2665-6; 20 Aug 2013 p. 3838; 18 Nov 2014 p. 4322; SL 2020/163 r. 42; SL 2021/164 r. 31.]

Form 2

Motor Vehicle Repairers Act 2003, s. 103(1) Withdrawal of infringement notice		Withdrawal no.
Alleged offender	Name: Family name
	Given names
	or Company name ____________________________________ ACN
	Address _________________________________________________ Postcode
Infringement notice	Infringement notice no.
	Date of issue / /20
Alleged offence	Description of offence ______________________________________
	Motor Vehicle Repairers Act 2003 s. OR Motor Vehicle Repairers Regulations 2007 r.
	Date / /20 Time a.m./p.m.
Person giving this notice	Name
	______________________________________ Signature
Date	Date of withdrawal / /20
Withdrawal of infringement notice [*delete whichever is not applicable]	The above infringement notice issued against you has been withdrawn. If you have already paid the modified penalty for the alleged offence you are entitled to a refund. * Your refund is enclosed. or * If you have paid the modified penalty but a refund is not enclosed, to claim your refund sign this notice and post it to: The Commissioner Department of Mines, Industry Regulation and Safety Consumer Protection Division Locked Bag 100 EAST PERTH WA 6892 Signature / /20

[Form 2 inserted: Gazette 24 Jun 2008 p. 2832-3; amended: Gazette 30 Jun 2011 p. 2666; SL 2021/164 r. 32.]

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