Self Exclusion - National Lotteries and Gaming Regulatory Board

Section A

Self Exclusion Details

Desired Exclusion Period *

Self Exclusion Reason *

Section B

Consent Details

By signing this form, I agree to voluntarily exclude myself from all gaming/betting activities. I understand that this is my decision, made without any undue influence or coercion, and that I should seek support should need be. * I agree to my personal information being used to enforce this self-exclusion. * I am aware that self-exclusion is a serious decision and that there is treatment available to help with gambling/betting problems. * I consent to be assigned a counselor

Consent Date *

Section C

Geographical Location

District *

County *

Sub County

Parish

Village

Section D

Personal Information

ID Type *

ID Number *

First Name *

Last Name *

Other Name

Date Of Birth *

Gender *

Contact *

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Operators Excluded From * Ctrl/Cmd-click to select multiple

Section E

Upload Supporting Documents

Attachments

Passport Photo

Self Exclusion Details

Consent Details

Geographical Location

Personal Information

Upload Supporting Documents

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