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Tiffany R Rolon EX-188 3015-2013

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

Author: admin

Tiffany R

Rolon

EX-188

3015-2013

Tue, 10/29/2013 - 20:00

Tiffany_R_Rolon.pdf40.71 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:

Home Address

Address

Address 2

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State/Province

ZIP/Postal Code

PHONE NUMBER:

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DATE AND APPROX TIME OF INCIDENT:

Incident Date

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Complaint Number:

Complaint Number

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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