Full Name
|
Contact Information (Physical Address, Phone Number, or Other Means of Contacting You Through Another Person)
|
Internet Address
|
Facts Supporting Summary (Date, Location, Description of human rights incident)
|
Identification of Other Witnesses to Human Rights incident
|
Name, Unit or Agency, if known, of Abuser (Including Rank, Position, or other identifying Information)
|
Contact Information, if known, of Perpetrator
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Do you authorize the release of this Summary to non-governmental organizations (NGO’s), international organizations
or foreign governments for the purpose of research or establishing commemorative museums, Pamphlets, or histories
of the atrocities suffered by the Iraqi People?
Yes
No
|
If the answer is yes to the above, do you authorize the release of your name and contact information?
Yes
No
|
Do you desire to have your Summary sealed in an envelope until it is turned over to the Iraqi Interim Authority?
Yes
No
|
