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

Incident Number:

(Do not write on above section)

Petition Form
Petitioner	Name		Affiliation
	Gender		Student ID Number or Position
	Mobile Phone		E-mail Address
Subject Matter
Department Involved			Department Representative / Contact Info.
Details of Petition		* Please attach additional pages as needed.
Date: Petitioner: (signature) SNU Ombudspersons Office