FOR OSCE CENTRE USE ONLY Registration number Received on (dd/mm/yy) Please carefully read the attached description of the mandate of the OSCE Centre in Cornucopia. If you wish to lodge a complaint about a human rights violation with the OSCE Centre, please fill in this form. Please attach copies of relevant documents, such as court decisions, results of medical examinations, etc. Information provided by you will be treated as confidential. After your complaint has been considered, an OSCE staff member will contact you. 1. First name: Last name: Citizenship (citizen of Cornucopia, refugee, stateless person, other – please indicate): Date of birth: Sex: M F Contact address: Phone/fax/e-mail: Alternate contact information: If you are NOT the victim of the alleged human rights violation, please also fill in the following: 2. Victim’s first name: Victim’s last name: Victim’s citizenship (citizen of Cornucopia, refugee, stateless person, other – please indicate): Date of birth: Sex: M F Contact address: Phone/fax/e-mail: A3 Alternate contact information: Your relationship to the victim: 119