Human Rights / Discrimination Complaint Form

1. Applicant
Name*			Date of birth				Nationality
Telephone no. (Mobile no.)*
E-mail
2-1. Victim (If you are filing a complaint on behalf of another individual)
Name*			Date of birth				Nationality			Relationship to the applicant*
Telephone no. (Mobile no.)*
E-mail
2-2. Does the victim know that you are complaining on behalf of him/her? (Please select one, if you are filing a complaint on behalf of another individual)
① Yes, and the victim needs help. ( ) ② Yes, but the victim does not need help. ( ) ③ No, the victim does not know about the application. ( ) ④ Yes, but it is unknown whether he/she wants help. ( )
3. Person(s) you are complaining against
Name				Position
Contact
4. Details on the incident(s) of human rights violations and racial discrimination*
① Date						② Place
③ Contents (Write a summary of the incident(s) you are complaining about. You are recommended to answer the following questions listed below. Use additional sheets if necessary.) 1) What is the relationship between the victim and the offender(s)? 2) What happened? 3) How did the victim react when the incident(s) occurred? 4) How did the offender respond to the victim’s reaction? 5) What is remedy/resolution the victim is seeking?

*Marked items are obligatory to fill out.

5. Evidence or materials for verifying the stated human rights violations or racial discrimination

6. References

□ Yes / File Name:                                                                        □ No

Consent on Personal Information Collection and Use

1. Purpose: To receive consultation applications, verify applications, provide answers to questions, conduct investigations, and notify results.

2. Items of personal information to collect: Name, date of birth, nationality, telephone number, and e-mail address.

3. Period of retaining and using personal information: Three (3) years from the date of consultation termination or upon the request of the Information Owner to delete the personal information.

4. You may reject the Agreement of Collecting and Using Personal Information, in which case you are limited in applying for consultation or filing a salvage claim.

* The collected personal information shall not be used for any purpose other than those defined above.

□ I hereby agree with the above stated Consent.

Date :

Applicant                     (Signature)

Gyeonggi Institute of Research and Policy Development for Migrants’ Human Rights

※ Note

- When filing an application, you should fill in information and contents precisely.

- Application revision can be requested, when the purpose applied is not clear due to the lack of facts and contents.

- If you need more space for describing details and contents of the incident(s), you can use additional sheets. In this case, it is recommended to add page numbers.

- If you are a member of an entity, it is advisable to elect a representative and to file a case in the name of the representative.

- If you have additional documents related with the incident(s), submit an application form with attached documents.

※ Who can apply

Person concerned, or a citizen or an entity in Gyeonggi province who finds that a third person has been infringed on human rights or racial discrimination.

※ How to apply

- On-line application

- E-mail: gmhr@gmhr.or.kr (Scan and transmit an application form with signature or seal)

- Fax: 031-492-9349 (Scan and transmit an application form with signature or seal)

※ Cases below may be excluded from consultation

- In case a person concerned does not want to proceed the investigation applied by a third person.

- In case, regarding human rights violations, court trials, investigations by official organization or other programs according to laws and ordinances are in progress.

- In case there is no reason to investigate, or false accusation, or in case an applicant obviously has other purposes.

- In case the same matter has already been consulted.