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Thomas Khotinsky EX-199 3174-2013

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

Author: admin

Thomas

Khotinsky

EX-199

3174-2013

Tue, 01/21/2014 - 19:00

Thomas_Khotinsky.pdf62.28 KB

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NAME OF INDIVIDUAL FILING A DISPUTE OR COMPLAINT

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HOME ADDRESS:

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Address

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PHONE NUMBER:

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DATE AND APPROX TIME OF INCIDENT:

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ONLINE SITE USED:

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USER/SCREEN NAME USED:

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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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