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Kahnawake Gaming Commission
Interactive Gaming Self-Exclusion Request Form
 

ONLINE GAMBLING

Comprehensive Self-Exclusion Request

Please read carefully

The Kahnawake Gaming Commission (KGC) is committed to all aspects of player protection. If you believe your online gambling activities have become a problem, this Comprehensive Self-Exclusion Request form will assist in permanently excluding you from gambling on all online gambling sites that are licensed and regulated by the KGC.

When you complete and submit the Comprehensive Self-Exclusion Request form below, you are authorizing the KGC to direct its present and future licensees to exclude you from accessing, depositing funds and playing on each and every one of the online gambling systems that are licensed and regulated by the KGC.  You are also authorizing the KGC’s agents to be provided the personal information contained in your Comprehensive Self-Exclusion Request so that they can check to make sure licensees are respecting your Comprehensive Self-Exclusion Request.

IMPORTANT:  ONCE IT HAS BEEN SUBMITTED TO THE KGC, YOUR COMPREHENSIVE SELF-EXCLUSION REQUEST IS PERMANENT AND CANNOT BE REVOKED.

Once a Comprehensive Self-Exclusion Request is received, the KGC will act as quickly as possible to notify all of its licensees that they must use their best efforts to exclude you from gambling on their online gambling systems.  The KGC will contact you by telephone for further information to assist the KGC and the licensees in fulfilling your request.  Your cooperation is very important to ensure there are no delays in processing your request.

When it has sent notifications of your Comprehensive Self-Exclusion Request to all its licensees, the KGC will email you with a precise date and time on which your Comprehensive Self-Exclusion Request has been put into effect (the “Time Stamp”).

IMPORTANT:  YOUR COMPREHENSIVE SELF-EXCLUSION REQUEST IS EFFECTIVE AS OF THE DATE AND TIME SET OUT TIME STAMP.

If you are still able to access any gambling system that is licensed by the KGC after the date and time indicated in the Time Stamp, or you receive any email or other materials advertising the gambling services offered any a KGC licensee, please notify the KGC immediately at exclusion@gamingcommission.ca.

If you have any questions, or require any additional information about this Comprehensive Self-Exclusion Request form or the process the KGC follows to put your Comprehensive Self-Exclusion Request into effect, please contact us at exclusion@gamingcommission.ca.

Fields outlined in red must be filled in, fully and correctly.  Incomplete or incorrect information will prevent or delay the KGC from taking action to fulfill your request.

Name:
Birthdate:        
Country of Residence:
Province/State:
City:
Email:
Please Confirm Email:
Telephone:
e.g. +1-450-835-1111
Best Time of Day to Call:
Primary Gambling Site:
User ID:
Secondary Gambling Site:
User ID:
Comments:
Form Verification:
 

I have read, understood and agree with the information on this page concerning my Comprehensive Self-Exclusion Request. In particular, by submitting this Comprehensive Self-Exclusion Request, I am agreeing that:

  1. My Comprehensive Self-Exclusion Request is Permanent and cannot be revoked.
  2. The KGC may provide my personal information to existing licensees, future licensees and the KGC’s agents, for the purpose of affecting my Comprehensive Self-Exclusion Request.
  3. My Comprehensive Self-Exclusion Request is effective from the date and time indicated in a Time Stamp that will be provided by the KGC.
  4. My exclusion is limited to those gaming systems that are now licensed and regulated, or that are licensed and regulated in the future, by the KGC.
  5. The KGC will use its best efforts to ensure my Comprehensive Self-Exclusion Request is affected as quickly as possible.  However, I understand and agree that the KGC, its members, employees, advisors, agents and governing body are not responsible for any damages or losses that I sustain as a result of, or related to, my gambling activities, both before and after the date and time indicated in the Time Stamp.