This form may be used to initiate contact with a gambling counsellor to discuss excluding an individual from a nominated registered club’s gaming machine areas.

If you have any queries in relation to this form, please contact the ClubSafe counselling line on 1800 99 77 66.

This field is for validation purposes and should be left unchanged.
Nominator Name(Required)
Nominator Address(Required)
Privacy Policy & Collection Notice(Required)