Application for Self-Exclusion from Non-Casino Gambling Operators

Transcription

1 Application for Self-Exclusion from Non-Casino Gambling Operators Part I: Personal Particulars Name (as in NRIC/FIN/Passport) - USE BLOCK LETTERS Gender: Male Female NRIC / FIN No. (Compulsory): Date of Birth (dd/mm/yyyy): Contact Number: Passport No.: (Compulsory for Non-Residents) Citizenship: Singapore Citizen Permanent Resident Foreigner Type of Singapore Identification (for Non-Residents only): Work Permit Work Permit (FDW) Long-Term Visit Pass Employment Pass S Pass Dependent s Pass Nationality: Student Pass Others Please specify: Race: Religion: Block / House No: Floor / Unit: Street: Building Name: Address: Postal Code: Highest Qualification Attained: Never attended school GCE O or N Level Others (Please ITE / Vocational Cert GCE A Level specify: Polytechnic Diploma or equivalent University Degree and Above Part II: Request for Additional Services (Please note that charges may apply for non-residents) I would like to be contacted by a counsellor to talk about my gambling. Yes No

2 Part III: Applicant s Declaration YOU MAY ONLY APPLY FOR SELF-EXCLUSION FROM BETTING ACCOUNTS OF WHICH YOU ARE AN EXISTING BETTING ACCOUNT HOLDER. I have an existing Singapore Pools Betting Account I would like to apply for Self-Exclusion from Singapore Pools Betting Account a. I request that the above Account be suspended until such time that I instruct Singapore Pools in writing to modify, withdraw or rescind this self-exclusion. b. I understand and accept that I will not be able to, and shall not attempt to use the Account to place bets and/or to access selected Account-related services during the suspension of the Account. c. I understand and accept that the self-exclusion applies only to the Account as identified by me in this form, and that Singapore Pools will not be responsible for ensuring that I am excluded from betting at the Singapore Pools outlets or through any other accounts. d. I understand and accept that the self-exclusion will remain in force for a minimum period of twelve (12) months, and shall continue in force unless and until Singapore Pools receives my written request to modify, withdraw or rescind it. e. I understand and accept that I cannot modify, revoke, withdraw or rescind this self-exclusion within twelve (12) months from the date of activation of this self-exclusion. f. I agree that the Terms and Conditions for Opening & Operating of a Betting Account as set out in the Terms and Conditions Governing Betting Accounts, which I have read and understood, shall remain binding and in force; g. I understand that this self-exclusion is made voluntarily and does not place any obligation, duty or responsibility on anyone except myself; h. I hereby unconditionally release Singapore Pools and its employees, servants, agents, contractors and representatives and those with whom they may lawfully share information regarding this self-exclusion (the Released Persons) from, and waive all my rights against the Released Persons in relation to, all actions, suits, claims and demands whatsoever which, but for this document, could now or hereafter be asserted, brought or made by me, or by anyone on my behalf, arising from any damage or injury or otherwise caused directly or indirectly as a result of any act, default or omission of the Released Persons in relation to this self-exclusion, and in the event that I comply wholly or in part or fail to comply with this self-exclusion; and i. I will indemnify and keep indemnified Singapore Pools and its employees, servants, agents, contractors and representatives (the Indemnified Persons) against all actions, liabilities, proceedings, losses, claims, damages, costs and expenses which the Indemnified Persons may suffer, incur or sustain in connection with or arising directly or indirectly from any act, default or omission by or on behalf of the Indemnified Persons in relation to this self-exclusion. j. I agree and accept that Singapore Pools may at its sole discretion forward my particulars to the National Council on Problem Gambling and its related organizations.

3 YOU MAY ONLY APPLY FOR SELF-EXCLUSION FROM BETTING ACCOUNTS OF WHICH YOU ARE AN EXISTING BETTING ACCOUNT HOLDER. I have an existing Singapore Turf Club Betting Account I would like to apply for Self-Exclusion from Singapore Turf Club Betting Account a. I confirm that I am making this application for a Self-Exclusion voluntarily. I have not been forced by any person to do so. b. I confirm that where I have applied for Self-Exclusion from a Betting Account, I am the Betting Account holder. My application for Self-Exclusion from a Betting Account will not be implemented if I am not the Betting Account holder at the time of my Self-Exclusion application. c. I understand and agree that the Self-Exclusion will stay in force indefinitely, unless I apply to revoke it (and the application for revocation has been registered and processed). d. I agree that I will only apply to revoke the Self-Exclusion after 12 months from the date of my e. I understand and agree that if and when I apply to revoke the Self-Exclusion, the National Council on Problem Gambling (NCPG) may contact me to invite me to attend an interview. f. I understand and agree that the gambling operator(s) should do its best to enforce the Self-Exclusion while it is in force, by whatever means it sees fit and is able to implement (i.e. to prevent me from entering or remaining in the gambling area or take part in any gaming on the gambling operator's premises, or suspending/closing my betting account etc). g. I agree that neither NCPG nor the gambling operator(s) shall be responsible for any loss or damage which may result from my application for Self-Exclusion, the granting or enforcement of the Self- Exclusion, or any failure on the part of the gambling operator(s) to enforce the Self-Exclusion. h. I further declare that all the information provided by me in this application is true and correct.

4 YOU MAY ONLY APPLY FOR SELF-EXCLUSION FROM JACKPOT ROOMS (PRIVATE CLUBS) OF WHICH YOU ARE AN EXISTING MEMBER. I would like to apply for Self-Exclusion from the Jackpot Rooms of the following Private Clubs, of which I am a member: AUPE Sports & Recreation Club The Chevrons Civil Service Club Club HDB The Grassroots Club HomeTeamNS Home United Football Club JOM-Clubhouse for Police Officers MND Recreation Club Nanyang Technological University Alumni Club People s Association Staff Club Public Utilities Board Recreation Club PWD-BCA Club SAFRA National Service Association SAF Yacht Club Sembawang Country Club Senior Police Officers Mess Club Singapore Polytechnic Graduates Guild Temasek Club Warriors Football Club National Service Resort & Country Club NTUC Club a. I confirm that I am making this application for a Self-Exclusion voluntarily. I have not been forced by any person to do so. b. I confirm that where I have applied for Self-Exclusion from a Jackpot Room, I am a member of the said Private Club. My application for Self-Exclusion from a Jackpot Room will not be implemented if I am not a member of the Private Club at the time of my Self-Exclusion application. c. I understand and agree that the Self-Exclusion will stay in force indefinitely, unless I apply to revoke it (and the application for revocation has been registered and processed). d. I agree that I will only apply to revoke the Self-Exclusion after 12 months from the date of my e. I understand and agree that if and when I apply to revoke the Self-Exclusion, the National Council on Problem Gambling (NCPG) may contact me to invite me to attend an interview. f. I understand and agree that the gambling operator(s) should do its best to enforce the Self-Exclusion while it is in force, by whatever means it sees fit and is able to implement (i.e. to prevent me from entering or remaining in the gambling area or take part in any gaming on the gambling operator's premises, or suspending/closing my betting account etc).

5 g. I agree that neither NCPG nor the gambling operator(s) shall be responsible for any loss or damage which may result from my application for Self-Exclusion, the granting or enforcement of the Self- Exclusion, or any failure on the part of the gambling operator(s) to enforce the Self-Exclusion. h. I further declare that all the information provided by me in this application is true and correct. Name of Applicant (as in NRIC/ID) / Signature Date Witnessed 1 by: Name of Witness (as in NRIC) / Signature NRIC No.: Contact No. (Home/Office): Contact No. (Mobile): Relationship to Applicant: Address: Date Your Self-Exclusion will come into effect within the next 7 days from the date as notified by 2 NCPG upon acknowledgement of your application. If you applied for Self-Exclusion from the Jackpot Rooms of Private Clubs, please do not enter or remain in the gambling area or take part in any gaming on the selected operators premises from the date of your If you applied for Self-Exclusion from Singapore Pools/Singapore Turf Club Betting Account, please do not access your betting account to engage in gambling activities from the date of application for Self- Exclusion. YOUR APPLICATION FOR SELF-EXCLUSION WILL NOT BE IMPLEMENTED IF YOU ARE NOT A MEMBER OF THE PRIVATE CLUB AND/OR BETTING ACCOUNT HOLDER AT THE TIME OF YOUR APPLICATION FOR SELLF- EXCLUSION. Important Note: All application forms must be accompanied by a photocopy (front and back) of the applicant s NRIC, Foreigner ID and/or Passport. NCPG only accepts application forms with original signature ie. not photocopies. NCPG reserves the right to reject incomplete application forms. For Administrative Use Mode of Submission: In Person By Hand By Post Received By: Processed By: Date: Time: Date: Ref No: