Application For Statewide Self-Exclusion
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Applicant Initials: ________
For MGC Office Use Only:
Missouri List of Disassociated Persons
VCode: ___________________
Application for Statewide Self-Exclusion
Location: ___________________
(also known as the Voluntary Self-Exclusion Program)
Instructions - Read carefully
Read the entire form, the Voluntary Self-Exclusion Program Rules (11 CSR 45-17), and the statewide self-exclusion guidelines
before responding to the questions.
Print legibly in blue or black ink.
Include a recent photo and a (clear/legible) copy of a valid driver's license or other government-issued photo identification card
.
Important Notice
This form is to be completed by a person who is concerned he or she is a problem gambler and who is requesting to be excluded from
gambling activities at all licensed excursion gambling boats in the State of Missouri. Pursuant to 11 CSR 45-17, by signing and
submitting this application, you are agreeing to refrain from visiting all Missouri casinos (excursion gambling boats) for the rest of
your life.
The Missouri Gaming Commission recommends you seek treatment for your gambling problem. Free treatment is available for
both problem gamblers and their family. To obtain the most recent information about treatment services, discuss your gambling
problem with someone, or if you have had thoughts of suicide, please call 1-888-BETS-OFF (1-888-238-7633). The number is
staffed 365 days per year, 24 hours per day.
Section 1: Personal Information
I read and understand English
8 Ethnic Origin:
1
African
African-American
Alaskan Native
An interpreter read and explained this form to me
(Complete
American Indian
Asian
Caucasian East Indian
the “Interpreter Information & Affirmation” form)
Hispanic Middle Eastern Pacific Islander Unknown
2 Full legal name of individual requesting voluntary self-
exclusion:
9 Noticeable Physical Characteristics:
(birthmarks, scars, tattoos, etc.)
First: ________________________________________
Middle: ______________________________________
________________________________________
Last:
10 Address: ___________________________________
Suffix: Jr. Sr. II III IV
Street, Apt / PO Box
3 Other names/alias/nicknames/maiden name used:
_______________________________ ______________
_______________________________________________
City
State
First name
Middle
Last name
________________________ _____________________
Male
Female
Country / Province
Postal Code
4 Gender:
_______________________
__________________________________
(MM / DD / YYYY)
5 Date of birth:
County of Residence
6 SSN (OR Other Taxpayer Identification Number):
11 Telephone Number(s):
Social Security # (SSN):
_______________________
- or -
Primary Phone ________________________________
International ID # (non-US ID): _______________________
Cell Phone ___________________________________
In accordance with Section 5 of the Privacy Act, 7 U.S.C. 522a, disclosure of your
Social Security Number (“SSN”) to the MGC is voluntary. Failure to provide your
Home Phone _________________________________
SSN is not grounds for denial of your request for placement on the List of
Disassociated Persons; however, omission of your SSN may increase processing
Work Phone __________________________________
time. If provided, your SSN may be disclosed to appropriate personnel of MGC and
Missouri licensed casinos to enforce rules of 11 CSR 45.
12 E-mail Address:
7 Physical Description:
_______________________________________________
Height: ____′ ______″ Weight (lbs): _________
Auburn Bald
Black
Blonde
13 Have you ever applied for statewide self-exclusion?
Hair
Yes
No
Red
Salt Pepper
Brown
Gray
Color:
Strawberry White
Other
Sandy
14 Have you ever been approved for statewide self-
Black
Blue
Brown
Gray Green
Eye
exclusion in Missouri?
Yes
No
Hazel
Maroon
Multi
Pink
Other
Color:
DAP FORM: APP 8.1‐201312
Page 1
APPL as amended 18 December 2013
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