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 have a gambling problem and therefore wish to be excluded immediately from all of Ayrshire Hospice’s gambling related activities, including receiving any gambling related marketing materials from Ayrshire Hospice, for a minimum period of: (required)

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).

Title

Name: (required)

Address: (required)

Town: (required)

Post Code: (required)

Date of Birth (required)

Email: (required)

Contact Telephone No: (required)

I acknowledge my responsibility in ensuring adherence to this agreement. I acknowledge that the Promoter, its employees or agents have no liability or claims arising from my voluntary use of the gambling facilities provided

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