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Lordes Maria Ortiz EX-096 2695-2012

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

Author: admin

Lordes Maria

Ortiz

EX-096

2695-2012

Tue, 07/31/2012 - 20:00

Lordes_Maria_Ortiz.pdf43.84 KB

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NAME OF INDIVIDUAL FILING A DISPUTE OR COMPLAINT

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HOME ADDRESS:

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PHONE NUMBER:

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DATE AND APPROX TIME OF INCIDENT:

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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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