Form Test Page - JACK Entertainment

Surveillance Video Release

Date(Required)

Time(Required)

Name and License Number of Issuer:(Required)

Name, License Number and Team Recipient:(Required)

iTrak Incident or Daily Log Number:(Required)

Description of Incident and Evidence to be Released:(Required)

Recipient's Purpose for Obtaining the Evidence:(Required)

Signature of Issuer:(Required)

Signature of Recipient:(Required)

The release of this surveillance video is governed by OAC 3772-19-08 and JACK Cleveland Casino LLC’s Internal Controls, Section P: Surveillance. By signing this form, the recipient acknowledges that the use of this evidence is limited to the specific purpose identified by the recipient and is not to be disseminated any further.

Form Test Page | JACK Entertainment

Surveillance Video Release