SELF-EXCLUSION FROM LICENSED PREMISES NOTICE OF TERMINATION OF AGREEMENT Under section 76 of the Liquor Act 2007
Title: ..............................................................
Please note: The following information is optional
Gender: ......................................................... Phone (home):.............................................. First name: .................................................... Phone (daytime): .......................................... Middle name: ................................................ Phone (mobile): ............................................ Family name: ................................................ Email: ........................................................... Date of birth: ................................................. Address:........................................................ ...................................................................... State: .................. Post Code:....................... _____________________________________________________________________________ Termination of Agreement Self-exclusion participant to complete To the Licensee Please take note that I wish to terminate the self-exclusion agreement I currently have in place in relation to .......................................................................................................................................... premises name I understand that the self-exclusion from licensed premises agreement will cease to be valid from the date the licensee signs this notice, and the terms agreed to will no longer be enforced. Self-exclusion participant to sign: ...................................................................................................... Date: ........................................... Licensee to complete I ...........................................................................acknowledge that I have received this request for licensee print name termination of the self-exclusion agreement detailed above and I agree to terminate the agreement effective immediately. Licensee to sign: ................................................................................................................................ Date: .......................................... The termination of the self exclusion agreement will not be valid until the self-exclusion participant and the licensee have signed and dated this termination of agreement notice. The licensee must sign this notice upon receipt from the participant. This original signed notice should be retained by the licensee. A copy of this signed notice must be provided to the self-exclusion participant. Page 1 of 1
Form approved by the Casino, Liquor and Gaming Control Authority on 30 April 2009 v1