Self Exclusion Form


We want your entertainment with us to be fun and we are vigilant and help those who need it. Occasionally some people have problems with gambling and it stops being fun. If this happens to you then there are many avenues to turn to for help, we are one of them and we will do our best to assist you. All of our management have received guidance and training in helping those that need it and you can always speak directly with Patrick who will do all he can to help.

We offer a self-exclusion scheme that enables a player to ask us to exclude them from all of our clubs and websites for upto 5 years. By completing this form you will ensure that you are not allowed to enter the premesis or log in to any Palatial Leisure site for the specified period of time. Once completed the exclusion will start immediately and it cannot be withdrawn under any circumstances until the exclusion time has expired.


First Name:
Surame:
Address:
Town / City:
County:
Postcode:
Email:
Exclude me for: 6 Months
1 Year
2 Years
3 Years
5 Years

Please provide as much infomation as you can about your membership of our clubs and website below. The more information that you provide the easier it will be for us to help you. Don't worry if you don;t know some of the information, just provide what you can and we will search our member databases and complete the rest so that we can ensure your complete exclusion from all of our clubs and sites.


Member?Club/SiteMembership Number(s)
Bingo
Casino
Online

Is there anything else that you think would help us to help you? Please provide any additinal information that you think may assist us such as alternative membership numbers, aliases, contact information or ways to identify you.


I confirm the following:


I understand that exclusion will be immediate and will include all Palatial Leisure premesis and websites. The exclusion cannot be withdrawn under any circumstances and at the end of the exclusion period membership can only be re-instated by making contact with us by telephone or in person. Exclusion applies to our businesses only, you are recommended to contact other businesses in the area and request exclusion even if you are not a member.