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In the space below, state your grievance. Be as specific as possible. If this is an academic grievance include the host university and advisor’s name. Please identify any specific policy or procedure you believe was applied to you unfairly, or the basis for any claim of unlawful discrimination against you (for example, race, sex, disability, etc.). Describe the basis of your grievance using as many factual details as you can (include the person(s) involved, the date and the approximate time). If you need additional space, please attach a brief statement to this form.*

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