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Garrett Taylor IG-EX-07 10595-2022

Create: Wed, 11/01/2023 - 11:16

Author: rmcgarvey

Garrett

Taylor

IG-EX-07

10595-2022

Wed, 07/26/2023 - 11:16

PublicAdvisory EX-01330_0.pdf289.62 KB

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NAME OF INDIVIDUAL FILING A DISPUTE OF COMPLAINT

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LAST NAME:

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Last?

HOME ADDRESS:

Home Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

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:

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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