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. For more information about third-party exclusions allowable under the Gaming Code of Practice, you can access the Code here. If you have any queries in relation to this form, please contact gamingcode@clubsnsw.com.au.

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)

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