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Vaylon Wong EX-294 3757-2014

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

Author: admin

Vaylon

Wong

EX-294

3757-2014

Tue, 01/13/2015 - 19:00

vaylon_wong.pdf119.56 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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ZIP/Postal Code

PHONE NUMBER:

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DATE AND APPROX TIME OF INCIDENT:

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Complaint Number:

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ONLINE SITE USED:

Online Site Used*

DEVICE TYPE:

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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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