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Imad Georgei Farah EX-326 3461-2014

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

Author: admin

Imad Georgei

Farah

EX-326

3461-2014

Tue, 04/28/2015 - 20:00

imad_farah.pdf140.82 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:

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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