Contact (OT)

Name*

First Last

Student Number

Brock Email Address*

Phone

Campus Extension

Permanent Mailing Address

Street Address City Province Postal Code

Summer Mailing Address

Street Address City Province Postal Code

Level of Study

International Student

Major

Year of Study

Gender

Before coming to the Ombuds Office, who did you speak with about your issue? Check all that apply

How did you hear about the Office?

Nature of Issue

Do you have an appointment scheduled about this issue?*

Parties Present

Date

Time

: HH

MM

Room #

Please outline in point form, your reason for requesting Ombuds assistance:

Contact