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Sherice Woolfolk-Yarborough EX-101 2736-2012

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

Author: admin

Sherice

Woolfolk-Yarborough

EX-101

2736-2012

Tue, 09/11/2012 - 20:00

Sherice_Woolfolk-Yarborough.pdf48.61 KB

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NAME OF INDIVIDUAL FILING A DISPUTE OR COMPLAINT

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LAST NAME:

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HOME ADDRESS:

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Address

Address 2

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PHONE NUMBER:

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DATE AND APPROX TIME OF INCIDENT:

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ONLINE SITE USED:

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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