Application for Consultation

Date of Consultation:

Consultant:                       (signature)

Name		Position		Phone
Affiliation	(College, Department, Lab, etc.)			Email
What kind of matters do you want to consult? ① Sexual harassment/Sexual violence ② Human rights violation ③ Unfair action of SNU ④ Complaints about unreasonable administrative system of SNU ⑤ Other (Please specify: ) 2. In case of sexual harassment or sexual violence, please select any of the below that applies to your case. ① Sexual harassment or sexual violence ② Gender discrimination ③ Dating violence ④ Trauma of sexual violence ⑤ Other (Specify: ) 3. In case of human rights issues other than sexual harassment/sexual violence, please briefly explain about the case. 4. Agreement to collection and use of personal information SNU Human Rights Center may collect and use your personal information for a purpose of consultation. The personal information you provided herein will be used until the consultation is over. You have a right to refuse collection and use of your personal information by the Human Rights Center. I fully understand the terms and agreement stated above. I hereby confirm my informed consent with regards to the collection and use of personal information. Name: (Signature)

SNU Human Rights Center