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* Indicates required field
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* First Name: |
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* Last Name: |
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* Street Address: |
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* City: |
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State (US only): |
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State/Province: (Non-US only) |
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* Zip/Postal code: |
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* Country: |
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E-mail: |
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* I am a
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Non-Scientologist
Public Scientologist
Staff Member
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Post: |
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* I am a parishioner of:
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* I am staff of:
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Church of Scientology
Mission of Scientology
Other
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* Church: |
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* Mission: |
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* Other: |
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Case level: |
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Training level: |
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Occupation: |
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Place of employment: |
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Date of Birth: |
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Any additional information you want to provide about yourself:
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IMPORTANT MESSAGE
This report is to include facts; a fact is defined in HCO PL 26 April 1970R, Revised 15 March 1975, THE ANATOMY OF THOUGHT as A FACT is something that can be proven to exist by visible evidence. An OPINION is something which may or may not be based on any facts. If the report concerns something that is suspected or not a fact as per the definition above, please state this in your report and also note:
TIME,
PLACE,
FORM and
EVENT.
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* I am reporting on:
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An org or portion of an org
Person(s)
Other
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A Church
A Mission
Other
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* Church: |
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Area (Division) |
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* Mission: |
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Area (Division) |
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* Other Organisation:
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* Other:
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* First Name: |
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* Last Name:
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Other: |
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Additional person:
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First Name: |
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Last Name:
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Additional person:
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First Name: |
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Last Name:
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Additional person:
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First Name: |
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Last Name:
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Additional person:
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First Name: |
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Last Name:
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Additional person:
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First Name: |
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Last Name:
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Additional person:
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First Name: |
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Last Name:
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Additional person:
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First Name: |
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Last Name:
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Additional person:
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First Name: |
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Last Name:
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Additional person:
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First Name: |
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Last Name:
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Copies of this report go to:
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* Type of Report: |
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* Type your report:
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I attest that the report is true and sent from the person it is said to be being sent from:
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Name:
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