Self-Ban or Self-Exclusion

Self-Ban or Self-Exclusion From Casino or Card Room


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 signed.  

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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