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Michael Zimorowicz EX-128 2854-2012

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

Author: admin

Michael

Zimorowicz

EX-128

2854-2012

Tue, 12/11/2012 - 19:00

Michael_Zimorowicz.pdf54.38 KB

PENNSYLVANIA

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NAME OF INDIVIDUAL FILING A DISPUTE OR COMPLAINT

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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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Incident Date: 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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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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