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Justin Dale Campbell EX-775 5437-2017

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

Author: admin

Justin Dale

Campbell

EX-775

5437-2017

Tue, 11/07/2017 - 19:00

justin_campbell.pdf123.21 KB

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NAME OF INDIVIDUAL FILING A DISPUTE OR COMPLAINT

First Name

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LAST NAME:

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HOME ADDRESS:

Home Address

Address

Address 2

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State/Province

ZIP/Postal Code

PHONE NUMBER:

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DATE AND APPROX TIME OF INCIDENT:

Incident Date

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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:

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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