Involuntary Exclusion – Family and Club Initiated

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Current: Third-Party Exclusion Contact Form
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Complete

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 - 1800 99 77 66.

Date of Request

Club

Nominator First Name

Nominator Last Name

Nominator Phone

Nominator Email

Nominator Address

Relationship to Player

Preferred Contact Method

Preferred Contact Time

Additional Comments (Optional)

I have read the ClubsNSW Privacy Policy and Collection Notice and understand how you collect and manage my personal information.*

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