This Casino, Card Room or Casino in
cooperation with the below signed patron agrees to honor their Self-Ban
from entering this casino for life. The
undersigned has indicated that they are a problem gambler and that by
executing this agreement, it will assist them in their recovery from the
Illness of Pathological Gambling DSM-IV (Section 312.31) Pathological Gambling
(Impulse Control Disorder).
In the event the undersigned changes
their mind and requests to have this self-ban cancelled, they may not re-enter
this casino or card room for one (1) year from the date this document was
In the event the undersigned returns to
the casino in violation of this agreement, they will be subject to immediate
removal and should they play, they will not be paid any jackpots or
other winnings. The undersigned patron agrees to permit this gaming facility
to share their self-ban information with other Casinos, card rooms, casinos or
any statewide gaming central data administration.
Neither this Casino nor Card Room will
be held liable for any cause of action in the execution of this mutually
agreed upon form.
Data on Self Excluded Person
NAME ADDRESS CITY, STATE, ZIP SOCIAL SECURITY #
Signature of Gaming Employee Date of Patron Self-Ban
Signature of Patron Date of Self-Exclusion
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