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Labeebah Muhammad EX-690 5111-2017

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

Author: admin

Labeebah

Muhammad

EX-690

5111-2017

Tue, 05/16/2017 - 20:00

labeebah_muhammad.pdf121.82 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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Last?

HOME ADDRESS:

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Address

Address 2

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State/Province

ZIP/Postal Code

PHONE NUMBER:

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DATE AND APPROX TIME OF INCIDENT:

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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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While NOT REQUIRED to file a complaint, after completing this form, if you have items (texts, screen shots, emails, etc.) relating to this complaint, you can send them in a separate email. For instructions, please reference the confirmation email that will be sent you once this form is submitted

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