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INSTRUCTIONS FOR VOLUNTARY EXCLUSION FROM CASINO GAMBLING 1. Please read the instructions and the Request for Voluntary Exclusion from Casino Control Gambling form (“Request Form”), including the waiver and acknowledgement, carefully. By signing and submitting the Request Form, you are acknowledging that you are a problem gambler and agreeing to be excluded from all gaming activities at Virgin Islands licensed casinos for at least the next ____________ ( ) year(s) (Choose between one (1) to three (3) years).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, or collect winnings or recover losses. Also, the casinos are to remove your name from their direct marketing lists. 2. The completed Request Form must be submitted in person by the person requesting self- exclusion at the following location during normal business hours: Casino Control Commission 3005 Orange Grove St. Croix, Virgin Islands Telephone: (340)718-3616 3. You must bring with you identification that contains your signature and a photograph such as a driver’s license, passport, or military identification card. 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 self-exclusion requests 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 purposes 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 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 on the lookout for you if you are discovered attempting to gamble while the self-exclusion list. 5. Your name will remain on the self-exclusion list for one to three year(s) unless you file a petition for removal that is granted be the Commission; however, you may not file more than one such petition within the one to three year(s) period of exclusion. Virgin Islands Casino Control Commission 3005 Orange Grove Christiansted, VI 00820 Telephone: 340-718-3616  Fax: 340-718-3136 info@casinocontrolcommission.vi VICCC INSTRUCTONS FOR VOLUNTARY EXCLUSION 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. However, 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. 7. For the complete rules governing the Self-Exclusion program, see 32 Virgin Islands Rules and Regulations §423.2.1 et seq. BY SIGNING BELOW, I REPRESENT THAT I HAVE READ THIS DOCUMENT, INSTRUCTIONS FOR VOLUNTARY EXCLUSION, AND FULLY UNDERSTAND ALL ITS TERMS. DATE: __________________ ________________________________ SIGNATURE I certify that on the ______ of _____________________ 20____, ___________________________ personally appeared before me and executed this document. _____________________________ My Commission Expired: ______________________ NOTARY PUBLIC REQUEST FOR VOLUNTARY EXCLUSION FROM CASINO GAMBLING This form is to be completed by a patron requesting to be excluded from gaming activities at all Virgin Islands Casinos. The information contained 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 10. HEIGHT: ______________________ 10. WEIGHT: _______________________ FT-IN LBS PLEASE CHECK APPROPRIATE BOX: 11. GENDER:  (M) MALE 12. HAIR COLOR: 13. EYE COLOR:  (F) FEMALE  (BK) BLACK  (BK) BLACK  (BR) BROWN  (BR) BROWN  (BD) BLOND  (HZ) HAZEL  (RD) RED  (BL) BLUE  (GY) GREY  (GY) GRAY  (WH) WHITE  (GR) GREEN  (BA) BALD  (OT) OTHER  (OT) OTHER 14. OTHER DISTINGUISHING PHYSICAL CHARACTERISTICS: ______________________________ VICCC REQUEST FOR VOLUNTARY EXCLUSION 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 Casino Control Commission to direct all Virgin Islands casino licensees to restrict my gaming activities for a period of one to three years from the date of this request or until such time as the Commission removes my name from the self-exclusion list in response to my written request to terminate my voluntary self-exclusion. I am aware and agree that during any period of 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. DATE: ________________ ________________________________ SIGNATURE I certify that on the ______ of _____________________ 20____, ___________________________ personally appeared before me and executed this document. _____________________________ My Commission Expired: ________________ NOTARY PUBLIC 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 o this Request for Voluntary Exclusion was forwarded to all licensed Virgin Islands casinos. CASINO CONTROL COMMISSION DATE: _____________________ BY: _______________________________