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Section 1: Term of Exclusion (Select One)
Government-Issued ID Type *:
Other Names used
Hair Color *:
Member of OLG rewards or Player's Club?
Eye Color
Gender *:
Ethnicity
Race
Signature HereClick to Sign
04/07/2026Click to Sign
Signature HereResponsible Gambling Specialist Will Sign Here
04/07/2026
Average Daily Money Spent at a sportsbook/lottery
How often do you gamble?
How did you hear about the Self-Exclusion Program?
x

Additional Signatures Required

Valid Government Issued Identification (with photo) Click Here to Upload