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Rain Le EX-026 1945-2011

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

Author: admin

Rain

Le

EX-026

1945-2011

Tue, 07/19/2011 - 20:00

rain_le.pdf83 KB

PENNSYLVANIA

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303 Walnut Street, Commonwealth Tower, 5th Floor
Harrisburg, PA 17101
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EMPLOYEE WEB EMAIL | REPORT A WEBSITE ISSUE

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NAME OF INDIVIDUAL FILING A DISPUTE OR COMPLAINT

First Name

First Name?

LAST NAME:

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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.

agreement

understand

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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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