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James Fredrick Lewis EX-124 2526-2012

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

Author: admin

James Fredrick

Lewis

EX-124

2526-2012

Tue, 12/11/2012 - 19:00

James_Fredrick_Lewis.pdf39.87 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

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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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