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Miguel A. Rivera EX-119 2165-2011

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

Author: admin

Miguel A.

Rivera

EX-119

2165-2011

Tue, 04/10/2012 - 20:00

Miguel_A_Rivera.pdf50.94 KB

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NAME OF INDIVIDUAL FILING A DISPUTE OR COMPLAINT

First Name

First Name?

LAST NAME:

Last Name

Last?

HOME ADDRESS:

Home Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

PHONE NUMBER:

Phone Number

EMAIL ADDRESS:

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DATE AND APPROX TIME OF INCIDENT:

Incident Date

Incident Date: Date

Incident Date: Time

COMPLAINT TYPE:

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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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