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Chaya Shimon EX-611 4935-2016

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

Author: admin

Chaya

Shimon

EX-611

4935-2016

Tue, 12/13/2016 - 19:00

chaya_shimon.pdf298.3 KB

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NAME OF INDIVIDUAL FILING A DISPUTE OR COMPLAINT

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LAST NAME:

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Last?

HOME ADDRESS:

Home Address

Address

Address 2

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State/Province

ZIP/Postal Code

PHONE NUMBER:

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DATE AND APPROX TIME OF INCIDENT:

Incident Date

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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.

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