Gambling Equipment Malfunction Report

Notification required within 72-hours of discovering malfunction.

Operator Name (Establishment) *

Your Name *

Phone Number *

Date of Incident*

Time of Incident*

System Manufacturer

Version of Equipment*

Description of malfunction*

Was there an unusual event that preceded
the incident? (Power Outage, Surge?)*

YES

If yes, please describe.

Did you pull surveillance recordings?*

YES

Were customers affected? Describe:*

Describe troubleshooting attempts and any
contact with equipment manufacturer:*