Application For Statewide Self-Exclusion Page 2
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3Applicant Initials: ________
Application for Statewide Self‐Exclusion (Placement on Missouri List of Disassociated Persons)
Applicant Name:
Section 1: Personal Information – Continued
17 Gambling activities with which I have the most problems:
15 Does your job require you to enter a Missouri casino floor in
Slots
Poker
Blackjack
Pai-Gow
performance of your job duties?
Yes
No
Roulette Bingo
Keno
Video Poker
Lottery
Sports
Horse/Dog Races
If yes, please provide the following information:
Internet Stocks Other:___________________
Employer: _________________________________
18 How did you learn about the Voluntary Exclusion
Job Title: ________________________________
Program?
(check all that apply)
Gaming License #:__________________________
Brochure/Literature
Gaming Commission
Signs/Info at the Casino
Casino Employee
Location(s) at which access is/may be needed:
Family Member
Mental Health Provider
Co-Worker/Friend
Web site
Helpline (1-888-Bets-Off)
Billboard/radio/television advertisement
Other:_____________________________________
16 Driver’s License / ID Card: (Attach a photocopy)
19 What are your main reasons for deciding to voluntarily
ID Number:______________________________
exclude yourself from Missouri’s casinos?
Type:
Driver’s License
State ID
Passport
(check all that apply)
To gain control
Need help
Military ID
Hit rock bottom
Advice of others
Naturalization Card
Referred by casino employee
Exp. Date: (MM/DD/YYYY) ________________
Referred by a Counselor
Referred by helpline
Save marriage
Save job
Prevent suicide
To support friend/loved one
Other:_____________________________________
Section 2: List of Disassociated Persons Self-Exclusion Guidelines
Note: Pursuant to 11 CSR 45-17, individuals requesting placement on Missouri’s List of Disassociated Persons (“List”) must read, agree to,
and understand the following self-exclusion guidelines before completing this request for statewide self-exclusion. If the individual has any
questions about placement on the List, the individual should contact the DAP staff at the Jefferson City MGC office (573 / 526-4080).
1. You must personally and voluntarily complete a request for statewide self-exclusion.
2. Your identity and eligibility for placement on the List will be verified.
3. The MGC will notify each Class B Licensee once a request for statewide self-exclusion has been made, verified,
and approved.
4. You agree you will not enter or attempt to enter a Missouri excursion gambling boat during the time period you
are on the List. (Any licensee may impose restrictions, including denial of access to any amenities in Missouri or
other jurisdictions, and may deny you access to gambling facilities in other jurisdictions.)
5. Any points or complimentaries you may have earned prior to placement on the List will be forfeited.
6. You will notify the MGC of any errant mailing or marketing offer you might receive from a Class B licensee
while on the List.
7. The consequences of you violating this agreement are criminal trespass charges and denial of any winnings
resulting from gambling while on the List of Disassociated Persons.
8. It WILL BE YOUR responsibility to stay out of all Missouri riverboat casinos.
9. It WILL NOT be the responsibility of the Commission, nor any of the various casino companies, to stop you
from entering a Missouri excursion gambling boat.
10. Disclosure of certain information is necessary to implement and enforce your request for self-exclusion. Your
information will be added to a statewide self-exclusion database. Disclosure may also occur if needed for the
conduct of an official investigation or if ordered by a court of competent jurisdiction.
11. You will notify the commission within thirty (30) days of any changes to the information provided in Section 1.
12. Your name will remain on the List indefinitely. You may apply to the Commission to have your name removed
from the List no sooner than five years after placement on the List.
13. If you apply for and have your name removed from the List, and later reapply to be placed on the List, your
placement on the List is irrevocable for life.
DAP FORM: APP 8.1‐201312
Page 2
APPL as amended 18 December 2013
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