Contents of the Application

The application for voluntary self-exclusion shall require provision of, at a minimum, the following content: (1) Name, home address, email address or telephone number, date of birth, and last four digits of social security number of the applicant; (2) A passport style photo of the applicant without headwear, unless worn daily for religious purposes and provided that the applicant's facial features are not obscured; (3) A statement from the applicant that one or more of the following apply: (a) they identify as a problem gambler as defined in 205 CMR 133.01; (b) they feel that their gambling behavior is currently causing problems in their life or may, without intervention, cause problems in their life; or (c) there is some other reason why they wish to add their name to the list. (4) An election of the duration of the exclusion in accordance with 205 CMR 133.04; (5) An acknowledgment by the applicant that the individual will not enter the gaming area of a gaming establishment or any area in which pari-mutuel or simulcasting wagers are placed for the duration of the exclusion period (except as provided by 205 CMR 133.02(1)) and that it is their sole responsibility to refrain from doing so; (6) An acknowledgment by the applicant that they shall not collect any winnings or recover any losses resulting from any gaming activity at a gaming establishment for the duration of the exclusion period; (7) An acknowledgment by the applicant that they will forfeit all rewards or points earned through a player reward card program; An offer by the commission or the designated agent completing the self-exclusion application to assist the applicant to access information about gambling disorders, self-guided help, peer-support, or counseling services with a clinician approved by the Massachusetts Department of Public Health or otherwise licensed or certified through a process or program recognized by the commission; (9) An acknowledgment of understanding by the applicant that by placing their name on the voluntary self-exclusion list the prohibitions identified in 205 CMR 133.02(1) apply to all gaming establishments licensed bythe commission in Massachusetts, anyaffiliates of the gaming licensee, whether within Massachusetts or another jurisdiction, and that the commission may share the list with other domestic or international gaming jurisdictions resulting in placement on those lists and may share such portion of the list with designated agents as may be necessary for the purpose of administering the voluntary self-exclusion program; An acknowledgment by the applicant that they are submitting the application freely, knowingly, and voluntarily; (11) A statement that the individual is not under the influence of a substance or suffering from a health or mental health condition that would impair their ability to make an informed decision; (12) An acknowledgment by the applicant that if they violate their agreement to refrain from entering a gaming area of a gaming establishment or any area in which pari-mutuel or simulcasting wagers are placed during the exclusion period, the applicant shall notify the commission of such violation within 24 hours of their presence within the gaming area of the gaming establishment or any area in which pari-mutuel or simulcasting wagers are placed; An agreement releasing the Commonwealth of Massachusetts, the commission, the licensee, and all affiliated employees from any claims associated with the applicant’s breach of the agreement; and (14) An acknowledgment by the applicant that once their name is placed on the self-exclusion list they may be refused entry and/or ejected from the gaming area of a gaming establishment by the gaming licensee, an agent of the commission, or law enforcement personnel