Name, Surname *

Car registration No.: *

I acknowledge, that I am *: the owner or the holder of the car
(according to the car registration licence)
the user of the car

Declared place of residence: *

Mailing address: *

Tel.:

E-mail:   Receive a reply via e-mail

Company name: *

Complaint submitter’s name, surname: *

Car registration No.: *

I acknowledge, that *: the company mentioned is the owner or the holder of the car (according to the car registration licence)
the complaint submitter is the owner or the holder of the car (according to the car registration licence)
none of the above

Legal address: *

Mailing address: *

Tel.:

E-mail:   Receive a reply via e-mail

Penalty Claim No. *

Payment methode: * Paymachine
Mobilly
Contract Card
No payment for parking has been made

Penalty Claim No. *