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SELFEXCLUSION REMOVAL FORM Full Name: Last 4 Digits of SS#: XXXIX Date of Birth: Street Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Driver's License #: License State: Gender:

How to fill out self-exclusion request form

How to fill out self-exclusion request form

1. Start by downloading and printing the self-exclusion request form from the official website or obtain a physical copy from a treatment center.
2. Fill in your personal details such as name, address, contact number, and date of birth.
3. Provide information about the gambling establishments or websites you wish to self-exclude from. Include their names, addresses, and any other relevant details.
4. Specify the duration of self-exclusion. You can choose a specific time frame, such as six months or one year. Alternatively, you can opt for indefinite self-exclusion.
5. Read and understand the terms and conditions of the self-exclusion program. Ensure you agree to abide by the rules and restrictions set forth.
6. Sign and date the form to acknowledge your understanding and acceptance of the self-exclusion request.
7. Submit the completed form to the designated authority, which could be a treatment center, a gambling regulatory body, or the gambling establishments themselves.
8. Keep a copy of the form for your records.
9. If self-exclusion is successful, you will receive confirmation and be barred from participating in gambling activities at the specified establishments or websites.

Who needs self-exclusion request form?

1. Anyone struggling with problem gambling or who wishes to restrict their access to gambling establishments.
2. Those who feel they have lost control over their gambling habits or want to take a break from gambling.
3. Individuals who want to prevent themselves from accessing online gambling platforms or physical casinos.

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What is self-exclusion request form?

The self-exclusion request form is a legal document that individuals can fill out to voluntarily prohibit themselves from participating in gambling activities or access to gambling venues.

Who is required to file self-exclusion request form?

Individuals who recognize that they have a gambling problem and want to take proactive measures to prevent themselves from gambling are required to file a self-exclusion request form.

How to fill out self-exclusion request form?

To fill out a self-exclusion request form, an individual must provide personal information such as name, address, and identification details, as well as specify the duration of self-exclusion and any additional requirements stipulated by the gambling authority.

What is the purpose of self-exclusion request form?

The purpose of the self-exclusion request form is to help individuals who are struggling with gambling addiction to take responsible steps to prevent themselves from gambling and promote recovery.

What information must be reported on self-exclusion request form?

The information that must be reported on the self-exclusion request form typically includes the individual's name, contact details, date of birth, the duration of self-exclusion, and any other relevant personal identifiers.