SEXUAL HARASSMENT CONSENT FORM

NAME: ........................          SOCIAL SECURITY NO.:...................
ADDRESS: .....................          CITY: .................................
STAFF ELEMENT: ...............          HOME TELEPHONE NO.: ...................
MALE: ..... FEMALE: ..........          OFFICE TELEPHONE NO.: .................

SEXUAL PREFERENCE:
        Male - Female:...............   Male - Male: ..........................
        Female - Female: ............   All of the Above: .....................
                        None of the Above: .................

I consent to the following forms of sexual harassment:

        Salutatory Greetings: ...............................
        Eye - to - Eye Contact: .............................
        Eye - to - Bust Contact: ............................
        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,
                etc., to be used during sexual harassment.

        2.      Procurement and maintenance of various types of sustaining
                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.

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