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