Gambling self exclusion form

Self exclusion request form

First name

Last name

Email

Address

Address 2

City/Town

County

Post Code

For further information about how we will protect your personal information and your rights please click here.

Lottery Membership Number (if known):

Please exclude me from all lottery and raffle activity with immediate effect. I understand that by submitting this form, the exclusion will remain in place until I telephone to tell you that I wish to begin gambling again. Please note that by law the self-exclusion must apply for a minimum period of 6 months

Signed

Please sign the form

Date

Problem Gambling Support Services

You can seek advice and support from trained counsellors at BeGambleAware by calling the National Gambling Helpline on 0808 8020 133 or visit their website Software is available to prevent an individual computer from accessing gambling internet sites – please see www.gamblock.com for further information.

London’s Air Ambulance is licensed with the Gambling Commission to operate a lottery, under licence number 029691-N-311036-008 and 029691-A-314940-007 This licence is issued under the Gambling Act 2005 Registered Company Number: 2337239 Registered Charity Number: 801013 To read our privacy policy please visit londonsairambulance.org.uk/privacy