Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697640309670.pdf (Antigua and Barbuda)
Exclusion Form Front View Profile (compulsory) (optional) Attach passport size photo here Attach passport size photo here Exclusion notice Section 1: Details of person seeking exclusion (block letters please) Surname: Address: Given names: Gender: Male Female Date of birth: Phone number: Section 2: Details of person requesting the exclusion (if different to above) Surname: Address: : Given names: Gender: Male Female Date of birth: Phone number: Relationship to excluded person: Reason for requesting exclusion: Exclusion notice Section 3: Details of exclusion (block letters please) I wish to exclude myself from the following venue(s) (name and address of venue): For a period of (up to 6 months), from to Insert X to indicate areas of self-exclusion (more than one can be ticked) which is called ‘the Exclusion Area’.
All Locations in Antigua and Barbuda Entire premises as listed Gaming area only Betting facilities Table games only Gaming machines only Other (for example, Lottery) Provide details: Exclusion notice I request that I be excluded from the Exclusion Area as listed above for the period set out above which, subject to the cooling off period is “the Exclusion Areas and Period”.

I am the person named in this notice and shown in the attached photograph.
I am aware that there is a 3 day cooling off period after I sign this notice.

The Exclusion Period will come into force when the cooling off period finishes unless I notify the Licensee or Authority, during the cooling off period, that I have changed my mind.

I will not go into the Exclusion Area during the Exclusion Period.
If I breach this notice by going into the Exclusion Area during the Exclusion Period: I will immediately tell a staff member of the Licensee that I am self-excluded from the area; and I authorise the Licensee to take any steps it sees fit to stop me gambling in the Exclusion Area including removing me from the Exclusion Area.

If I gamble in the Exclusion Area during the Exclusion Period then I acknowledge that any such gambling is at my own risk.
If I gamble in the Exclusion Area during the Exclusion Period, contrary to this notice, and as a result suffer financial loss, then I agree not to make any claim against the Licensee or Authority for any financial or other loss that I may sustain as a result.

I have read and I understand this notice and attached information.

I have freely decided to exclude myself from the Exclusion Area for the Exclusion Period on the terms and conditions in this notice.
All references to “Licensee” mean the holder of the licence to conduct gambling activities in the Exclusion Area and includes the employees, contractors or agents of the Licensee.

All references to “the Authority” means the Antigua and Barbuda Gambling Authority and includes its employees, contractors and or agents Signature of applicant: Signature of witness: Address of witness: : Information Date: Date: This Exclusion Notice is an important document.
You should make sure you have read and understood it before filling it out.

You should consider whether you need independent legal advice on its contents.

The information provided below is a brief outline of the exclusion process and the rights and responsibilities of parties involved in self-exclusion.

Exclusion notice Process A person seeking exclusion from a venue should contact the Licensee of the venue, or the Gambling Authority directly to discuss their wish to be excluded.
If after considering the information provided, a person wishes to be self-excluded they should complete an Exclusion Notice.

Exclusion is available for a period of up to six (6) months.

Exclusion takes effect three (3) days after the Exclusion Notice is signed by the Licensee or the Authority.

The three day period is called the “cooling off” period and gives the applicant time to think about the decision and change their mind if they wish.
An Exclusion Notice lodged with either the Licensee of the venue or the Authority cannot be reversed after the end of “cooling off” period.

Exclusion Notices must be completed in full and may be lodged in person or by post.

If you wish to be excluded from more than one venue, a separate notice must be completed and provided to the Gambling Authority directly.
Rights and Responsibilities of the Excluded Person An excluded person must not try to enter any part of a venue they are excluded from during the period of self-exclusion.

Should an excluded person enter any part of the venue from which he or she is excluded, that person must advise the Licensee’s staff immediately when the person enters the exclusion area.
An excluded person accepts that if contrary to an Exclusion Notice they gamble in an area they are excluded from they do so at their own risk and they will not make any claim for any losses they may suffer.

Rights and Responsibilities of the Licensee of the Venue The Licensee must provide information about the assistance available to a person wishing to self- exclude.
The Licensee must remove an excluded person’s name from player loyalty mailing lists promoting gaming activities during a period of exclusion.

If an excluded person is discovered in, or attempting to enter, an area they are excluded from, the Licensee will take reasonable steps to prevent the excluded person’s further participation in the gambling activities therein including prohibiting their entry or continued presence in the area.
Getting Help If you require any further information on assistance available to you, contact: