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1 Request for Self-Exclusion from New Mexico Gaming Facilities Application Checklist: 1 OBTAIN YOUR APPLICATION Applications can be obtained from: New Mexico Gaming Control Board 4900 Alameda Blvd NE Albuquerque, NM Or from our website at: 2 Call to schedule an appointment with NMGCB agent. To schedule an appointment at a location near you, call the NMGCB main number: (505) for assistance. 3 Bring with you to your appointment a current driver s license or state issued identification card. A photo will be taken at the time or your appointment. Self-Exclusion Request Form v6.0
2 Self-Exclusion Instructions and Procedure The New Mexico Gaming Control Board (GCB) will make available a Request for Self-Exclusion form for any individual who wishes to self-exclude from gaming at any or all gaming facilities, including racetrack casino and/or Tribal gaming establishment. The person requesting self-exclusion must complete the entire form, leaving no space blank. The form must be signed by the person seeking self-exclusion, be properly notarized, and submitted to the GCB. A current color photograph showing only the head and shoulders of the person seeking self-exclusion must be included with the form. The exclusion is in effect immediately upon issuance of a Decision & Order approving the Request for Self-Exclusion. After the form is fully executed and notarized, the original form will be received and maintained by the GCB in a secure file. GCB will compile and distribute the list of self-excluded persons to the appropriate gaming establishment(s). Gaming establishments shall prohibit the payment of any hand-paid jackpot to a person who is on the self-exclusion list. Any jackpot won by a person on the self-exclusion list shall be used by the Gaming Establishment to fund or support programs for the treatment and assistance of compulsive gamblers pursuant to Section 4(B) (16) of the 2015 Compact and Section 60-2E-34.1(6) of the Gaming Control Act. The request for self-exclusion shall remain in effect during the full time period selected by the person requesting self-exclusion. The person s name will be removed from the self-exclusion list upon expiration of the time frame selected or upon a subsequent Decision and Order of the Board granting a request to be removed from the self-exclusion list. The list of self-excluded persons shall not be subject to public inspection. Self-Exclusion Request Form v6.0 Page 2
3 PLEASE PRINT Name: Last, First & Middle (Include Sr., Jr., etc. if applicable) Home Address: Number and Street Apt City, State and Zip Code Phone Number: Contact Phone #1 Contact Phone #2 Social Security #: Date of Birth: Driver s License #: Height: Feet Inches Gender: Issuing State: Weight: Lbs. Hair Color: Eye Color: Distinguishing Physical Characteristics: How long would you like to be excluded from gaming establishments? (see below) Minimum of 1 Year 5 Years Lifetime Other (specify) Which gaming establishment(s) would you like to be excluded from? (see below) Please initial in the box to the right of the gaming establishment(s). Ruidoso Downs Billy The Kid Casino Sunland Park Racetrack & Casino Sunray Park & Casino The Downs Racetrack & Casino Zia Park & Black Gold Casino All Racetrack Casinos *Gaming Facilities Statewide *(All Racetrack & Tribal Gaming Facilities) Affix a recent passport quality photograph here showing head and shoulders of person to be excluded. Photograph must be attached to complete application. Self-Exclusion Request Form v6.0 Page 3
4 Acknowledgement I hereby acknowledge my intent to voluntarily exclude myself from gaming establishments in the State of New Mexico that I have requested exclusion from and: I declare that I am a problem gambler and wish to be placed on the Board s List of Self Excluded Persons. (initial) I declare that I am capable of making an informed decision to voluntarily exclude myself from the designated gaming establishment(s). I declare that I am completing this application of my own free will, without undue influence or coercion from a third party. I understand that the list will be provided to each gaming establishment(s) and its employees and key executives from which I have requested exclusion in the State of New Mexico. I fully authorize the GCB and its staff to release my photo and the contents of this application to the gaming establishment(s) and the employees and key executives of these establishments from which I have requested exclusion in the State of New Mexico. I understand that a gaming establishment(s) is immune from liability arising out of its efforts to exclude me. I agree not to visit, enter or be present in the gaming establishment(s) from which I have requested exclusion in the State of New Mexico. I understand that it is not the responsibility of the GCB or the gaming establishment(s) to stop me from entering the gaming establishment(s) from which I have requested exclusion in the State of New Mexico. I fully understand that as a self-excluded person, if I am found to be present at a gaming establishment(s) from which I have been excluded, I will be subject to removal and I shall forfeit all winnings, credits, tokens or vouchers received by me while present at the gaming establishment(s). The winnings, credits, tokens or vouchers will be used by the gaming establishment to fund or support programs for the treatment and assistance of compulsive gamblers. I understand the GCB staff may contact me regarding the self-exclusion process. I agree to notify the GCB of any change in information provided in this application within 30 days of the change. I understand that I must remain on the self-exclusion list for a minimum of one year. All of the information provided by me in this application and acknowledgement is complete, truthful and accurate. Applicant s Printed Full Legal Name: Last, First and Middle (Include Sr., Jr., etc if applicable) Applicant s Signature: Must be witnessed by notary public State of: County of: Subscribed and sworn to before me by this day of, 20. My commission expires: Signed: Notary Public Signature or ID of Translator: Self-Exclusion Request Form v6.0 Page 4
5 DO NOT WRITE BELOW - FOR NMGCB PERSONNEL USE ONLY I CERTIFY THAT I ACCEPTED THIS REQUEST FOR VOLUNTARY SELF-EXCLUSION FROM GAMING ACTIVITIES. I VERIFY THE INFORMATION ON THE ABOVE-REFERENCED IDENTIFICATION CREDENTIAL AND THE SIGNATURE ABOVE APPEARS TO AGREE WITH THAT CONTAINED ON THE IDENTIFICATION CREDENTIAL, AND THE PHYSICAL DESCRIPTION AND PHOTOGRAPH OF THE PERSON ON THE IDENTIFICATION CREDENTIAL APPEARS TO AGREE WITH HIS OR HER ACTUAL APPEARANCE. PRINT NAME OF GCB EMPLOYEE EXCLUSION # S SIGNATURE OF GCB EMPLOYEE DATE Self-Exclusion Request Form v6.0 Page 5
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