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Lolita Houser EX-425 4288-2015

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

Author: admin

Lolita

Houser

EX-425

4288-2015

Tue, 11/17/2015 - 19:00

lolita_houser.pdf114.49 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

Address 2

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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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