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Benjamin Ronald Sullivan EX-307 3870-2014

Create: Thu, 07/13/2023 - 22:12

Author: admin

Benjamin Ronald

Sullivan

EX-307

3870-2014

Tue, 02/24/2015 - 19:00

benjamin_sullivan.pdf108.74 KB

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EMPLOYEE WEB EMAIL | REPORT A WEBSITE ISSUE

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NAME OF INDIVIDUAL FILING A DISPUTE OR COMPLAINT

First Name

First Name?

LAST NAME:

Last Name

Last?

HOME ADDRESS:

Home Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

PHONE NUMBER:

Phone Number

EMAIL ADDRESS:

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DATE AND APPROX TIME OF INCIDENT:

Incident Date

Incident Date: Date

Incident Date: Time

COMPLAINT TYPE:

Complaint Type (Choose One)

Complaint Number:

Complaint Number

ONLINE SITE USED:

Online Site Used*

DEVICE TYPE:

Device Type

USER/SCREEN NAME USED:

User / Screen Name Used

Please provide a summary of the incident or dispute to the best of your knowledge. Include any statements which you made to the licensed gaming entity's personnel or any statements you made to witnesses to the incident or dispute.

Please provide a summary of the incident or dispute to the best of your knowledge. Include any statements which you made to the licensed gaming entity's personnel or any statements you made to witnesses to the incident or dispute.

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