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Devaraja Chikkhhos EX-1296 20412-2022

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

Author: admin

Devaraja

Chikkhhos

EX-1296

20412-2022

Tue, 04/25/2023 - 20:00

Devaraja_Chikkhhos_0.pdf306.27 KB

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NAME OF INDIVIDUAL FILING A DISPUTE OR COMPLAINT

First Name

First Name?

LAST NAME:

Last Name

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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