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Protection of Conscience Project

www.consciencelaws.org

Service, not Servitude
Resources

Victim Worksheet

General Report - Part I

If you forward a copy of the General Report to the Project, please complete the following.

CONCERNS about CONFIDENTIALITY

In the space below, please indicate your concerns and give directions for the handling of your information.

Check Applicable Box

 

I am concerned that disclosure of this information could adversely impact my employment, application for employment or educational programmes, or professional standing.

 

I do NOT believe that disclosure of this information will have adverse consequences for me.

Other (explain)
 
 

DIRECTION for DISCLOSURE

The information in this report

 

May be disclosed to anyone working to support or advance protection of conscience legislation

 

The following restrictions apply: (Here state conditions or restrictions you wish to impose)

 
 
 

YOUR CONTACT INFORMATION

Your name:

 

Your address:

 
   
   

Your tel:

 

Your fax:

 

Your e-mail:

 


 

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