Self-exclusion notice – sports bookmakers
Self-exclusion notice – sports bookmakers /Applicant details
Sports bookmaker:
Nominated site:
Applicant (insert name):
Contact number (office): / Contact number (home):
Contact number (mobile):
Exclusion period: / Months / Years/Permanent
Self-exclusion notice
I apply to be excluded from the Nominated Site and telephone wagering in accordance with the NT Code of Practice for Responsible Online Gambling 2016.
In making this Self-Exclusion Notice, I acknowledge and accept the following:
1. I agree not to seek entry to or attempt to enter the Nominated Site or make or attempt to make a telephone wager for the Exclusion Period, which commences 3 days after today.
2. I understand that the Sports Bookmaker may remove my access from, or prevent me from entering, the relevant Nominated Site and I authorise the Sports Bookmaker to prevent me from entering or to remove my access from the relevant Nominated Site.
3. I understand that my personal details and the details of the exclusion will be placed on the Responsible Gambling Incident Register held by the Sports Bookmaker.
4. I understand that the Sports Bookmaker will not allow me or anyone else to use any account I have with the Sports Bookmaker for the Exclusion Period and I authorise the Sports Bookmaker to close any current account (after settlement of any outstanding bets).
5. I understand that my exclusion from the Nominated Site and telephone wagering is voluntary and does not place any obligation, duty or responsibility on any other person or body other than me and I further understand that this Notice is not a contract and it in no way binds the Sports Bookmaker, save to the extent required by law.
6. I agree to release, and covenant not to sue the Sports Bookmaker or its servants, agents or contractors (“the released persons”) from all actions, suits, claims, demands whatsoever, which but for this Notice, I could now or hereafter assert, bring or make, or by anyone on my behalf, arising from any damage or injury or otherwise caused directly or indirectly as a result of any act, default, or omission of the released persons in relation to the matters contained in this Notice.
7. I acknowledge that I had the right to seek independent legal or other professional advice before signing.
Signatures
Signature: / Date:
Signature of Witness:
Name and address of witness:
Contact numbers: office / Mob: / Home:
For further information – Licensing NT
Darwin
Level 3, NAB House
71 Smith St
Darwin NT 0800
GPO Box 1154
Darwin NT 0801
t: (08) 8999 1800
f: (08) 8999 1888 / Alice Springs
Level 1 The Green Well Building
50 Bath St
Alice Springs NT 0870
PO Box 8470
Alice Springs NT 0871
t: (08) 8951 5195
f: (08) 8951 5112 / Katherine
Ground Floor, Randazzo Building
16-18 Katherine Terrace
Katherine, NT 0850
PO Box 2138
Katherine NT 0851
t: (08) 8973 8810 or
(08) 8973 8811
f: (08) 8973 8867
Department of Business Page 2 of 2
June 2016