Application For Statewide Self-Exclusion Page 3
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3 Application for Statewide Self‐Exclusion (Placement on Missouri List of Disassociated Persons)
Applicant Name:
Section 3: Waiver and Release
I hereby release and hold the State of Missouri, the Missouri Gaming Commission and its employees, and all excursion
gambling boats in Missouri and their affiliated companies, employees, officers and agents harmless from any claim by me or any
third party for any harm, monetary or otherwise, which may arise out of or by reason of any act or omission relating to the request
for self-exclusion or maintenance or enforcement of the self-exclusion list, including, but not limited to, relinquishing the right to
any money or thing of value obtained by me from, or owed to me by, a Class B Licensee as a result of wagers made by me while
on the List of Disassociated Persons. I understand my presence on an excursion gambling boat constitutes trespassing and I
will be arrested for such, I am not eligible to place a legal wager on an excursion gambling boat in Missouri and I will be
denied the winnings based on any wager I might place on an excursion gambling boat.
Section 4: Acknowledgement and Signature
I hereby acknowledge the following:
Because I am a problem gambler, I am voluntarily requesting exclusion from the premises of all Missouri excursion gambling
boats, check-cashing privileges, the receipt of direct-marketing and promotional materials regarding gaming opportunities, and
collection of any winnings or recovery of any losses during the exclusionary period. I understand no further points, rewards or
benefits may be accumulated or redeemed from the player recognition programs I have participated in. I understand this self-
exclusion request does not release me from any liabilities incurred prior to or during the self-exclusion period. I understand that
during the self-exclusion period, any money or thing of value obtained by me from, or owed to me by, a casino as a result of
wagers made by me while on the self-exclusion list shall be relinquished. I hereby consent to having this form, my photograph and
identifying information, including my social security number, disseminated to necessary MGC and Class B Licensee personnel and
I hereby designate, constitute and appoint the Commission and any agent of the Commission as my agent and true and lawful
attorney-in-fact in my name, place, stead and on my behalf and for my use and benefit to release all contents of my application to
all Class A or B licensees (riverboat casino operators) and their employees and agents. I further consent to having said information
disclosed to casino affiliated companies outside of Missouri and that I may be excluded from those casinos without further action
on my part. I understand the Commission or its agents or employees may contact me at times to conduct research necessary to
evaluate the List of Disassociated Persons and determine appropriate methods of addressing problem gambling issues in Missouri.
I acknowledge that for my request of self-exclusion to be truly effective, I must exercise self-restraint and I shall not attempt to
enter the premises of any Missouri excursion gambling boat or ask any casino employee to assist me with any of the services or
privileges which are subject to this request. I acknowledge that I am hereby banned and forbidden from entering the premises of
any Missouri excursion gambling boat and that if I am found anywhere on the premises of a Missouri casino, I will immediately be
ejected, will be arrested, and prosecuted for criminal trespass pursuant to 11 CSR
45-17.
I certify the information I have provided
herein is true and accurate, and I am not presently under the influence of any alcoholic beverages, controlled substances,
or prescription medication which would prevent me from making a sober and informed decision. I further certify I have
read, understand, and agree to 11 CSR 45-17, this acknowledgement, the self-exclusion guidelines, as well as to the waiver
and release above. I execute it voluntarily and with full knowledge of its consequences and significance.
____________________________________________________
______________________
Signature of Applicant for voluntary statewide self-exclusion
Date
APPLICATION MUST BE SIGNED IN THE PRESENCE OF A MISSOURI GAMING COMMISSION AGENT
Section 5: Certification of Witness
= = = = T
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F
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P
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= = = =
HIS
ECTION
OR
OMMISSION
ERSONNEL
SE
NLY
I certify I have witnessed the signature(s) of the person requesting placement on Missouri’s List of Disassociated Persons and
the signature(s) appears to agree with that contained on the above identification credentials and any physical description or
photograph of the person appears to agree with his or her actual appearance.
I certify the individual appears to be sober and coherent, and to be accomplishing this application of his or her own free will. I
certify I have reviewed the application for accuracy and completeness, and I have accomplished and attached all necessary
supplemental information.
____________________________________________ ___________ ______________________
Signature of Commission/MSHP Agent
Badge #
Date
DAP FORM: APP 8.1‐201312
Page 3
APPL as amended 18 December 2013
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