Self Exclusion Review Form

Site Name

Site Address

Customer Name

Customer D.O.B

Customer Address

Review of Self-Exclusion agreement on

Customer Decision

Request to resume access to premises following a self-exclusion

I confirm that I no longer wish to be excluded from:

I have experienced a cooling off period of at least 24 hours

Terms and Conditions

In completing and sending this self-exclusion review form you agree to be withdrawn from the self-exclusion conditions previously imposed, and therefore access to the group’s gaming/gambling services will no longer be restricted.

Please tick here to agree to the terms and conditions

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