Self-Exclusion Request Form

Please complete this form to request to be self-excluded from participating in all lotteries and gambling services provided by: Havens Hospices RCN 1022119

Alternatively download the form here and return to us at FRadmin@havenshospices.org.uk

Self-Exclusion Request Form

This form is for individuals who wish to exclude themselves from participating in our lottery. Please complete all fields.

Name

First Last

Date of birth

Address

Street Address Address Line 2 City Post Code

Phone

Exclusion Request

I request to be self-excluded from participating in all lotteries and gambling services provided by: Havens Hospices RCN 1022119 I understand that: • I will not be able to participate in any of the organisation’s lottery draws, promotions, or gambling-related activities for the period of exclusion. • My details will be retained for the duration of the exclusion to help prevent my participation. • I must contact the organisation in writing if I wish to resume participation, and a 24-hour cooling-off period will apply.

Length of Self-Exclusion

Self-exclusion will begin on the date this form is received. It will remain in effect until a formal request for reinstatement is submitted and approved. For matters relating to self-exclusion please contact FRadmin@havenshospices.org.uk 01702 220305

Confirm you have read and agree to the terms of self-exclusion

First Last

Date