Name:______________________________  SOCIAL SECURITY
No:____________________
ADDRESS:___________________________
CITY:__________________________________
STAFF ELEMENT:_____________________  HOME PHONE
No.:________________________
MALE:___________ FEMALE:___________  OFFICE PHONE
No.:______________________
SEXUAL PREFERENCE: Male - Female
                   Female - Female
                   Male - Male
                   All of the Above
                   None of the Above - Please Specify:
_____________________
I CONSENT TO THE FOLLOWING FORMS OF SEXUAL HARRASSMENT:
Salutatory Greeting: _____________________
Eye-to-Eye Contact: ______________________
Eye-to-Bust Contatct: ____________________
Eye-to-Below Waist Contact: ______________
Heavy breathing on neck: _________________
                   ear: __________________
                   other: ________________
Hands on body: ___________________________
         shoulder: _______________________
         waist: __________________________
         Gluteus Maximus: ________________
         other: __________________________
Feelies: _________________________________
Gropies: _________________________________
Penetration (however slight): ____________
Other: ___________________________________
All of the Above: ________________________
MISCELLANEOUS:  I WILL          I WILL NOT
1.  Assist in procurement of various potions, lotions, products,
appliances,
    etc. to be used during sexual harassment.
2.  Assist in procurement and maintenance of various types of substaining
    apparatus.
3.  Clean up.
I CERTIFY THAT I WILL ACCEPT SEXUAL HARASSMENT FROM:
Anyone: __________________________________
Anyone But: ______________________________
Only: ____________________________________
SIGNATURE: _______________________________________ DATE:
____________________
This form is to be reviewed by immediate supervisor annually, prior to
performance rating and evaluation.