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David Silvestri EX-120 2095-2011

Create: Thu, 07/13/2023 - 22:14

Author: admin

David

Silvestri

EX-120

2095-2011

Wed, 08/17/2011 - 20:00

David_Silvestri.pdf133.94 KB

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NAME OF INDIVIDUAL FILING A DISPUTE OR COMPLAINT

First Name

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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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EMAIL ADDRESS:

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DATE AND APPROX TIME OF INCIDENT:

Incident Date

Incident Date: Date

Incident Date: Time

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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