Signature: ________________________________________
Signature: ________________________________________ Date: __________________________________ TYPE OF REPORT – PLEASE CHECK ONE PATRON COMPLAINT CRIME/OTHER VIOLATION CONTACT INFORMATION Your Name: _______________________________________________________________________________________________ Address: __________________________________________________________________________________________________ Home Phone: (______) __________________________________ Mobile Phone: (______) ____________________________ Email Address: ____________________________________________________________________________________________ SUMMARY OF INCIDENT Gaming Establishment where Incident Occurred: __________________________________________________________________ Table or Slot Machine Number: ____________________ Location Number: _____________________________ Date of Incident: ________________________________ Approximate Time of Incident: _______________________________ CASINO EMPLOYEES INVOLVED: ____________________________________________________ ___________________________________________________ …
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Signature: ________________________________________ Date: __________________________________ TYPE OF REPORT – PLEASE CHECK ONE PATRON COMPLAINT CRIME/OTHER VIOLATION CONTACT INFORMATION Your Name: _______________________________________________________________________________________________ Address: __________________________________________________________________________________________________ Home Phone: (______) __________________________________ Mobile Phone: (______) ____________________________ Email Address: ____________________________________________________________________________________________ SUMMARY OF INCIDENT Gaming Establishment where Incident Occurred: __________________________________________________________________ Table or Slot Machine Number: ____________________ Location Number: _____________________________ Date of Incident: ________________________________ Approximate Time of Incident: _______________________________ CASINO EMPLOYEES INVOLVED: ____________________________________________________ ___________________________________________________ ____________________________________________________ ___________________________________________________ WITNESS(ES) ____________________________________________________ ___________________________________________________ ____________________________________________________ ___________________________________________________ Describe in as much detail as possible the nature of incident, whether you reported this to the VI Casino Control Commission, the gaming facility’s security, or another authority, and if so, how they responded to the incident. Use additional pages if necessary. Virgin Islands Casino Control Commission 3005 Orange Grove Christiansted, VI 00820 Telephone: (340)718-3616 | Facsimile: (340)718-3136 Email: info@casinocontrolcommission.vi | Website: www.casinocontrolcommission.vi For Commission Use Only Incident No. SIGN