Self Exclusion Form - Gambling Commission - Licence Conditions and Code of Practice

If you feel you have a problem with gambling and would like to request we exclude you from receiving gambling related marketing material, you can simply complete and submit this form.

I acknowledge that I will not be allowed to rescind my self-exclusion during this period. Following our successful completion of your self-exclusion request:

• Your chosen self-exclusion period will remain in force with Ayrshire Hospice, for
a minimum of 7 years
• Ayrshire Hospice will not send you any gambling related marketing materials,
and until you specifically request us to do so.

Please ring the Ayrshire Hospice lottery helpline on 01292 288488, if you wish to extend your chosen self-exclusion period (minimum 6 months extension).