A. The Request
for Self-Exclusion form must include:
(1) The
following identifying information concerning the person submitting the
self-exclusion request:
(a) Name, including
any aliases or nicknames;
(b) Date
of birth;
(c) Address of current
residence;
(d) Current telephone
number;
(e) Social Security number,
if such information is voluntarily provided by the person requesting
self-exclusion;
(f) A physical
description of the person, including height, weight, gender, hair color, eye
color and any other physical characteristic that may assist in the
identification of the person;
(2) The length of the self-exclusion period
requested by the person:
The length of a self-exclusion period must be for one of the
following designated time frames: one year, three years, five years, or
lifetime. Once a time frame is selected, the person requesting exclusion will
serve the entire duration of the exclusion period except, in the case of
lifetime exclusion, the person may petition the Board for removal from the
self-exclusion list after five years.
(3) A signed release that includes, at a
minimum, the following:
(a) Acknowledgement
that the request for self-exclusion has been made voluntarily;
(b) Certification that the information
provided on the form is true and accurate;
(c) Acknowledgement that the individual
requesting self-exclusion is a problem gambler; and
(d) Agreement to release, indemnify, hold
harmless and forever discharge the State, the Board, and licensed slot
facilities and casinos from any claims, damages, losses, expenses or liability
arising out of, by reason of or relating to the self-excluded person or to any
other party for any harm, monetary or otherwise, which may arise as a result of
or by reason of any act or omission relating to the request for self-exclusion,
including:
(i) Its processing or
enforcement;
(ii) The failure of a
slot facility or casino to withhold gaming privileges from or restore gaming
privileges to a self-excluded person;
(iii) Otherwise permitting or not permitting
a self-excluded person to engage in gaming activity in a licensed facility
while on the list of self-excluded persons.
(e) Acknowledgement that any self-excluded
person violating the terms of his or her self-exclusion agreement during the
self-excluded period may be subject to (1) conviction for criminal trespass,
and/or (2) placement by the Board on the involuntary exclusion list as set out
in Section
5 of these
regulations.
