Pennsylvania's Self-Exclusion Program

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Self-ExclusionIrrevocableConsequences for Violation of Self Exclusion Forfeit Jackpot Escort Out; Citation or Arrest for Trespassing Additional days/months to Permanent Barr The State, Tribe, and/or Casino are not responsiblefor financial lossLarissa T. Pixler NCPG SE Interstate Comparison July 19, 201334
Please print clearly:Arizona Department of GamingSelf-Exclusion FormFullName: SS #:Date ofStreet Address:Birth:City:State:ZipCode:HomePhone:BusinessPhoneDriver’sLicense #/StateHeight: Weight: Hair: Eyes: Sex:Any other names used (a.k.a.):Scars/Tattoos:Race:__________I request information be mailed to me describing services available to help me with my gambling problem.(Initials required; no return address will be used.)Optional Information: Gambling activities that cause the most problems (mark all that apply) Slots PokerBlackjack Bingo Keno Horse/Dog Races Video Poker Lottery Sports Internet StocksI, _____________________________________, acknowledge that I am a problem gambler and voluntarily seek toexclude myself from Indian Gaming Facilities in Arizona. * With my initials, I hereby request and authorize theArizona Department of Gaming to place my name on the list of self-excluded persons for a period ofone year_____, five years_____, or ten years_____. (Initial the specific time period you are selecting.)Larissa T. Pixler NCPG SE Interstate Comparison July 19, 201335
Page 1 and 2: Liz Lanza, DirectorOffice of Compul
Page 3: A voluntary program to assist probl
Page 6 and 7: Is:• A forum for the problemgambl
Page 8 and 9: Self-excluded individuals identifie
Page 13: *Self-exclusions do not expire. Ind
Page 16: • Self-excluded individuals who r
Page 19 and 20: • As of June 1, 2013, there have
Page 21 and 22: Stephen L. Martino, DirectorMarylan
Page 23 and 24: The Maryland Voluntary Exclusion Pr
Page 25 and 26: Enrollment by Gender126118MaleFemal
Page 27 and 28: 80Duration Chosen by Gender70606469
Page 29 and 30: 6Violations5543322211102011 2012 20
Page 31 and 32: Self-Exclusion ProgramLarissa T. Pi
Page 33: Color Photograph• Close up of the
Page 37 and 38: Date________________ ______________
Page 39 and 40: 120010008006004002000Duration Chose
Page 41 and 42: MiddleEastern4%NativeAmerican2%Othe
Page 43 and 44: 7881005300025002000150010005000OneY
Page 45 and 46: 2-13 2-12 2-11 2-10 2-09 2-08 2-07
Page 47 and 48: Asian BlkCauc. Hisp. M.East Native
Page 49 and 50: Start Duration Violations Rscnd.Rqs

Pennsylvania's Self-Exclusion Program

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