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＊ Required

Name
Phone No.＊
Country＊
Title or name of depertment to report
at FUJIMI＊
Name of the board member or employee
to report at FUJIMI＊
Category of the report＊
Where the problem/violation occurred＊
When the problem/violation occurred＊
Detail on the problem/violation＊
Existence of evidence＊