Self-Exclusion form

Name: *

Address Line 1: *

Address Line 2:

Address Line 3:

Town/City: *

Postcode: *

Email Address: *

Telephone Number:

Please tick below your chosen self-exclusion period: *

6 months

1 year

2 years

5 years

Submitting this request enters you into the self-exclusion scheme as detailed in the Raffleplayer Problem Gambling and Self-Exclusion policy.

If you would like to enter our raffles and lotteries again after this period you can call our helpline on 01628 201283.

Please remember for friendly and helpful advice from trained counsellor’s call the National Gambling Helpline on 0800 8020133 or visit the GambleAware website www.begambleaware.org.