Expiation Notice No.:
PERSON SUBMITTING REQUEST
Full Name:
NOTE: If you are not the Notice Holder you MUST provide the Notice Holder’s Full Name below:-
Notice Holder’s Full Name:
If you are not the Notice Holder the review may be considered, however, generally only the Notice Holder will receive the outcome of the review. When you request a review, you may be required to provide additional information depending on the review reason. It is recommended that you attach evidence such as medical records, images and Police report numbers in support of your review submission. Further information regarding expiation notices, statutory declarations, nomination forms and photographic evidence can be found on the SA Police website http://www.police.sa.gov.au.
REASON FOR REQUEST
PREFERRED METHOD OF RESPONSE (tick one option)
I would like the response sent by:-
Email to the Notice Holder at:
Mail to the address on the expiation notice
Mail to Notice Holder at different address
Address:
Type name/initials or if printing sign here
Signature:	x	Date:	/	/
(Notice Holder / Person Submitting Request)
Email completed form to:	enb@police.sa.gov.au
OR Post to:	Manager, Expiation Notice Branch GPO Box 2029, ADELAIDE SA 5001