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Complainant
Name ( Last, First MI )
Address ( Street, City, State, ZIP )
Player Card Number
Phone
Best Time To Contact
Best Time To Contact: Date
Best Time To Contact: Time
Casino Involved
Casino Name
City Where Casino Is Located
Employee(s) Involved
Name ( Last, First, MI )
License Number
Job Title
Name ( Last, First MI )
License Number
Job Title
Witnesses
Name ( Last, First MI )
Address ( Street, City, State, ZIP )
Phone
Name ( Last, First MI )
Address ( Street, City, State, ZIP )
Phone
Gaming Device Involved (If Applicable)
Machine # Location
Denomination
Manufacturer
Serial Number
Detailed Description Of Incident
Location
Date Occured
Time Occured
Summary Of Incident
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