Report Day: 20   .    .    .                                                          Officer:                       (signature)

Incident Number:

(Do not write on red part.)

Application for Petition
Petitioner	Name		Affiliation
	Gender		Student ID Number or Position
	Mobile Phone		E-mail Address
Petition Title
Related Department			Related Person
Details of Petition		* Additional pages can be attached if needed.
Date: Petitioner: (signature) SNU Ombudspersons Office