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Virgin Islands Casino Control Commission Revised February 16, 2023 INSTRUCTIONS FOR VOLUNTARY EXCLUSION FROM CASINO GAMBLING 1. Please read carefully the instructions and the Request for Voluntary Exclusion from Casino Gambling (“Voluntary Exclusion Request”), including the waiver and acknowledgement. By signing and submitting the Voluntary Exclusion Request, you are acknowledging that you are a problem gambler and agreeing to be excluded from all gaming activities at United States Virgin Islands’ licensed casinos for____________ ( ) year(s) (Choose one (1), two (2), or three (3)). This means you cannot gamble, receive, or use complimentary goods or services, be a member of a slot or players club, receive credit from any casino, cash checks at a casino, collect winnings or recover losses for the chosen period. The casinos are to remove your name from their direct marketing lists. 2. Placement on the self-exclusion list is voluntary and can only be done by the individual seeking exclusion. Submission of the Voluntary Exclusion Request must be made in person at the following location during normal business hours (8:00 a.m.-5:00 p.m., Monday-Friday): Virgin Islands Casino Control Commission 3005 Orange Grove Christiansted, St. Croix, VI 00820 Tel: (340)718-3616 info@casinocontrolcommission.vi 3. You are required to bring with you a valid driver’s license, passport, military identification card, permanent resident card or other approved government issued identification that contains your signature and a clear photograph, when submitting the Voluntary Exclusion Request. Your photograph will be taken by Commission personnel. 4. Your photograph and identifying information will be distributed to appropriate casino personnel. The information contained in the Voluntary Exclusion Request and the self-exclusion list maintained by the Commission is not open to public inspection and every effort will be made to maintain its confidentiality. However, the Commission and casinos are not liable for any disclosures of such information other than a willfully unlawful disclosure. Certain limited disclosures by the casinos are permitted. The casinos may inform certain of their agents, including cash advance services and junket representatives, that you are on the self-exclusion list for the purpose of denying you gaming related services. The casinos also are permitted by law to disclose to affiliate gaming entities in this territory or other jurisdiction(s) that you are on the self-exclusion list for the limited purpose of the proper administration of responsible gaming programs administered by the affiliated gaming entities. Further, the casinos may alert other Virgin Islands casinos to be vigilant should you attempt to gamble while on the self-exclusion list. 5. Self-exclusion remains in effect until you request removal in writing. You must remain on the self- exclusion list for a minimum period of SIX (6) MONTHS. At the conclusion of the minimum period, you can request an early removal from the self-exclusion list, and the Commission can grant or deny Virgin Islands Casino Control Commission 3005 Orange Grove Christiansted, VI 00820 Telephone: 340-718-3616  Fax: 340-718-3136 info@casinocontrolcommission.vi VICCC REQUEST FOR VOLUNTARY EXCLUSION Virgin Islands Casino Control Commission Revised February 16, 2023 your request. If you are granted an early removal and you subsequently file another Voluntary Exclusion Request, you must remain on the self-exclusion list for the full period of years you chose in paragraph 1 and the Commission will deny any request for early removal 6. It is your responsibility to refrain from gaming activities. The Commission and the casino(s) are not liable for any acts or omissions in processing or enforcement of your request for self-exclusion, including failure to withhold your gaming privileges. If you are caught gambling at a casino, you will be subject to forfeiture of any winnings, including any chips, tokens, or electronic gaming device credits in your possession, and you will be escorted from the gaming floor. The Commission and the casino(s) also are not liable for any acts or omissions in processing or enforcement of any later request by you to be removed from the self-exclusion list. BY SIGNING BELOW, I REPRESENT THAT I HAVE READ THESE INSTRUCTIONS FOR VOLUNTARY EXCLUSION FROM CASINO GAMBLING IN THE UNITED STATES VIRGIN ISLANDS AND I FULLY UNDERSTAND ALL TERMS AND CONDITIONS. DATE: __________________ _____________________________________ SIGNATURE ACKNOWLEDGMENT STATE OF: ______________) COUNTY OF:______________) On this ______ day of _________________________, 20_____, before me, personally appeared, ________________________________________, proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he/she executed the said instrument for the purpose(s) stated therein. WITNESS my hand and official seal _____________________________________ NOTARY PUBLIC My Commission Expires: __________________________________ VICCC REQUEST FOR VOLUNTARY EXCLUSION Virgin Islands Casino Control Commission Revised February 16, 2023 REQUEST FOR VOLUNTARY EXCLUSION FROM CASINO GAMBLING This form is to be completed by the person requesting to be excluded from gaming activities at all Virgin Islands casinos. The information provided on this form is confidential. Please Print Or Type The Answers To The Following Questions In The Spaces Provided 1. Name: ______________________________________________________________________________ LAST (INCLUDE SR., JR., ETC., IF APPLICABLE) FIRST MIDDILE 2. DO YOU USE ANY OTHER NAME OR NAMES? YES ______ NO ______. IF YES, LIST ADDITIONAL NAME(S) BELOW (INCLUDE MAIDEN NAME, ALIASES, NICKNAMES OR ANY OTHER NAME): ____________________________________________________________________________________________ 3. HOME ADDRESS: _____________________________________________________________________________________ NUMBER AND STREET APT# _____________________________________________________________________________________ CITY STATE ZIP CODE 4. MAILING ADDRESS: _____________________________________________________________________________________ NUMBER AND STREET APT# _____________________________________________________________________________________ CITY STATE ZIP CODE 5. EMAIL ADDRESS: __________________________________________________________________ 6. HOME TELEPHONE NUMBER: ________________________________________________________ (AREA CODE) NUMBER 7. WORK TELEPHONE NUMBER: ________________________________________________________ (AREA CODE) NUMBER 8. MOBILE TELEPHONE NUMBER: ______________________________________________________ (AREA CODE) NUMBER 9. DATE OF BIRTH: ______________________________/_____________/_______________ MONTH DAY YEAR Virgin Islands Casino Control Commission 3005 Orange Grove Christiansted, VI 00820 Telephone: 340-718-3616  Fax: 340-718-3136 info@casinocontrolcommission.vi VICCC REQUEST FOR VOLUNTARY EXCLUSION Virgin Islands Casino Control Commission Revised February 16, 2023 10. PLACE OF BIRTH: ________________________________________________________________________ 11. HEIGHT: ______________________ 12. WEIGHT: _______________________ FT-IN LBS PLEASE CHECK APPROPRIATE BOX: 13. GENDER: 14. RACE/ ETHNICITY: 15. HAIR COLOR: 16. EYE COLOR:  (M) MALE  WHITE  (BK) BLACK  (BK) BLACK  (F) FEMALE  HISPANIC OR LATINO  (BR) BROWN  (BR) BROWN  X (Unspecified  BLACK OR AFRICAN AMERICAN  (BD) BLOND  (HZ) HAZEL Or Other Gender Identity)  NATIVE AMERICAN OR AMERICAN INDIAN  (RD) RED  (BL) BLUE  ASIAN / PACIFIC ISLANDER  (GY) GREY  (GY) GRAY  OTHER  (WH) WHITE  (GR) GREEN  (BA) BALD  (OT) OTHER  (OT) OTHER 17. OTHER DISTINGUISHING PHYSICAL CHARACTERISTICS: _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ VICCC REQUEST FOR VOLUNTARY EXCLUSION Virgin Islands Casino Control Commission Revised February 16, 2023 WAIVER AND RELEASE I hereby release and forever discharge the Government of the Virgin Islands including the Virgin Islands Casino Control Commission, its employees and agents, the Division of Gaming Enforcement, its employees and agents, and all casino licensees and their employees and agents from any liability to me and to my heirs, administrators, executors and assigns for any harm, monetary or otherwise, which may arise out of or by reason of any act or omission relating to my request for self-exclusion or relating to my request for removal from the self-exclusion list, including any processing or enforcement; any failure of a casino licensee to withhold gaming privileges from or restore gaming privileges to me; permitting me to engage in gaming activity in a licensed casino while on the list of self-excluded persons; and disclosure of the information contained in the self-exclusion request or list, except for a willfully unlawful disclosure of such information. ACKNOWLEDGEMENT I am voluntarily requesting exclusion from all gaming activities at all Virgin Islands licensed casinos because I am a problem gambler. I certify that the information that I have provided above is true and accurate, and that I have read and understand and agree to the waiver and release included with this request for self-exclusion. I am aware that my signature below authorizes the Virgin Islands Casino Control Commission to direct all Virgin Islands casino licensees to restrict my gaming activities for a period of (check) ( ) one (1) year, ( ) two (2) years, or ( ) three (3) years from the date below and that the voluntary self-exclusion will remain in effect until such time that the Commission grants my written request for removal. I acknowledge that I must remain on the self-exclusion list for a MINIMUM PERIOD OF SIX (6) MONTHS. I am aware and agree that during self-exclusion, I shall not collect any winnings or recover any losses resulting from any gaming activity at any licensed casino and that any money or thing of value obtained by me from or owed to me by a casino licensee as a result of wagers made by me while on the self-exclusion list, shall be subject to forfeiture. I understand that during the period of self-exclusion I will be deemed to be a trespasser upon entering any casino space in the Virgin Islands. DATE: ________________ ________________________________ SIGNATURE ACKNOWLEDGMENT STATE OF: ______________) COUNTY OF: _______________) On this ______ day of _________________________, 20_____, before me, personally appeared, ________________________________________, proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he/she executed the said instrument for the purpose(s) stated therein. WITNESS my hand and official seal ____________________________ NOTARY PUBLIC My Commission Expires: ________________________________ VICCC REQUEST FOR VOLUNTARY EXCLUSION Virgin Islands Casino Control Commission Revised February 16, 2023 DO NOT WRITE BELOW ------------- FOR COMMISSION PERSONNEL USE ONLY TYPE OF I.D. OFFERED: __________________________________________________________ I certify that the signature of the person requesting suspension of gaming privileges appears to agree with that contained on the above identification credentials, and that a physical description or photograph of the person on the identification credentials appears to agree with his or her actual appearance. CASINO CONTROL COMMISSION DATE: _________________ BY: _______________________________ I certify that a copy of this Request for Voluntary Exclusion was forwarded to all licensed Virgin Islands casinos. CASINO CONTROL COMMISSION DATE: _____________________ BY: _______________________________