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Dana Elbert Lee EX-057 2358-2011

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

Author: admin

Dana Elbert

Lee

EX-057

2358-2011

Tue, 02/28/2012 - 19:00

dana_elbert_lee.pdf231.98 KB

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NAME OF INDIVIDUAL FILING A DISPUTE OR COMPLAINT

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LAST NAME:

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HOME ADDRESS:

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Address

Address 2

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PHONE NUMBER:

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DATE AND APPROX TIME OF INCIDENT:

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Complaint Number:

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ONLINE SITE USED:

Online Site Used*

DEVICE TYPE:

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USER/SCREEN NAME USED:

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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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