Submitted by admin on Thu, 01/16/2020 - 14:24 Contact Details First Name Surname Email Contact Number Address Complaint Details Date of Incident MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year1992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022 Year Date You Became Aware of the Incident MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year1992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022 Year Are you complaining in behalf of someone? Yes No Do you know who did it? Yes No Personal Information Involved Name Identification Number Date of Birth / Age Place of Birth Telephone Number Home Address User Account Credentials Other Personal Information Involved Sensitive Information Involved Racial or Ethinic Origin Medical Records including disabilities Biometric Identifiers (e.g. fingerprint) Statement of Assets / Bank Account Information / Financial Records Religious Belief or Affiliations Political Opinions Marital Status Sexual Preferences and Practices Criminal Records Membership of a Political Association Membership of a Professional or Trade Association Membership of a Trade Union Other Sensitive Information Involved Please describe the incident. How it occurred? How have you been affected? I hereby certify that all the above information is true and correct to the best of my knowledge and belief. Required * I have read and understand the Terms of Use and PEZA's Privacy Policy. Required * Submit
