Form CGCC-CH7-05 "Self-exclusion Request" - California

What Is Form CGCC-CH7-05?

This is a legal form that was released by the California Gambling Control Commission - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2020;
  • The latest edition provided by the California Gambling Control Commission;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CGCC-CH7-05 by clicking the link below or browse more documents and templates provided by the California Gambling Control Commission.

ADVERTISEMENT
ADVERTISEMENT

Download Form CGCC-CH7-05 "Self-exclusion Request" - California

Download PDF

Fill PDF online

Rate (4.4 / 5) 27 votes
Page background image
State of California
California Gambling Control Commission
Self-Exclusion Request
CGCC-CH7-05 (New 05/20)
Page 1 of 2
MAIL COMPLETED FORM TO:
BUREAU OF GAMBLING CONTROL
P.O. Box 168024
Sacramento, CA 95816-8024
(916) 830-1700
PLEASE READ THE FOLLOWING INFORMATION CAREFULLY BEFORE YOU COMPLETE THIS FORM
All information must be typed or printed legibly in blue or black ink. Any questions that do not apply should be indicated with “N/A”
(Not Applicable). If the space available is insufficient, attach a separate sheet of paper and precede each answer with the applicable
section and question number. Any corrections, changes, or other alterations must be initialed and dated by the requestor.
Disclaimer: This request applies to all gambling establishments licensed by the California Gambling Control Commission
SECTION 1: PERSONAL INFORMATION
FULL NAME: LAST
FIRST
MIDDLE
ALIAS(ES), NICKNAME(S), OTHER FORMER LEGAL NAMES
RESIDENCE (STREET, CITY, STATE, ZIP CODE)
MAILING ADDRESS IF DIFFERENT THAN CURRENT RESIDENCE (STREET, CITY, STATE, ZIP CODE)
PRIMARY TELEPHONE NUMBER
SECONDARY TELEPHONE NUMBER
EMAIL ADDRESS
GAMES MOST OFTEN PLAYED
SECTION 2: EXCLUSION REQUEST
Initial Requested Term:
O
Y
L
NE
EAR
IFETIME
SECTION 3: PHOTO AND VISUAL DESCRIPTION
HEIGHT
WEIGHT
HAIR COLOR
EYE COLOR
DRIVER’S LICENSE/IDENTIFICATION CARD NUMBER
STATE
EXPIRATION DATE (MM/DD/YYYY)
DATE OF BIRTH
RACE/ETHNICITY
GENDER
AFFIX A RECENT
PASSPORT QUALITY
PHOTOGRAPH
DISTINGUISHING MARKS (SUCH AS VISIBLE SCARS OR TATTOOS – DESCRIBE MARK & LOCATION)
HERE SHOWING
HEAD AND
SHOULDERS OF
PERSON TO BE
EXCLUDED
MAKE AND MODEL OF VEHICLE NORMALLY DRIVEN
LICENSE PLATE
I understand English or have had an interpreter read and explain this form to me in ___________________.
(Language)
State of California
California Gambling Control Commission
Self-Exclusion Request
CGCC-CH7-05 (New 05/20)
Page 1 of 2
MAIL COMPLETED FORM TO:
BUREAU OF GAMBLING CONTROL
P.O. Box 168024
Sacramento, CA 95816-8024
(916) 830-1700
PLEASE READ THE FOLLOWING INFORMATION CAREFULLY BEFORE YOU COMPLETE THIS FORM
All information must be typed or printed legibly in blue or black ink. Any questions that do not apply should be indicated with “N/A”
(Not Applicable). If the space available is insufficient, attach a separate sheet of paper and precede each answer with the applicable
section and question number. Any corrections, changes, or other alterations must be initialed and dated by the requestor.
Disclaimer: This request applies to all gambling establishments licensed by the California Gambling Control Commission
SECTION 1: PERSONAL INFORMATION
FULL NAME: LAST
FIRST
MIDDLE
ALIAS(ES), NICKNAME(S), OTHER FORMER LEGAL NAMES
RESIDENCE (STREET, CITY, STATE, ZIP CODE)
MAILING ADDRESS IF DIFFERENT THAN CURRENT RESIDENCE (STREET, CITY, STATE, ZIP CODE)
PRIMARY TELEPHONE NUMBER
SECONDARY TELEPHONE NUMBER
EMAIL ADDRESS
GAMES MOST OFTEN PLAYED
SECTION 2: EXCLUSION REQUEST
Initial Requested Term:
O
Y
L
NE
EAR
IFETIME
SECTION 3: PHOTO AND VISUAL DESCRIPTION
HEIGHT
WEIGHT
HAIR COLOR
EYE COLOR
DRIVER’S LICENSE/IDENTIFICATION CARD NUMBER
STATE
EXPIRATION DATE (MM/DD/YYYY)
DATE OF BIRTH
RACE/ETHNICITY
GENDER
AFFIX A RECENT
PASSPORT QUALITY
PHOTOGRAPH
DISTINGUISHING MARKS (SUCH AS VISIBLE SCARS OR TATTOOS – DESCRIBE MARK & LOCATION)
HERE SHOWING
HEAD AND
SHOULDERS OF
PERSON TO BE
EXCLUDED
MAKE AND MODEL OF VEHICLE NORMALLY DRIVEN
LICENSE PLATE
I understand English or have had an interpreter read and explain this form to me in ___________________.
(Language)
Self-Exclusion Request
Page 2 of 2
SECTION 4: DECLARATION
I voluntarily seek to exclude myself as specified in Section 2 of this form.
(INITIAL HERE)
I agree that I will not attempt to enter or use any of the services or privileges of a California Gambling Establishment or
participating gambling facility during the period specified in Section 2.
(INITIAL HERE)
I acknowledge and understand that should I attempt to enter any Gambling Establishment or participating gambling facility or
use the services of any cardroom business licensee or participating gambling facility during the Term of Exclusion, once
identified, I will be escorted from the Gambling Establishment or participating gambling facility.
(INITIAL HERE)
I agree that any unredeemed jackpots or prizes I may have accrued will be forfeited and remitted by the cardroom business
licensee or participating gambling facility for deposit into the Gambling Addiction Program Fund for problem gambling
prevention and treatment services through the State Department of Public Health, Office of Problem Gambling.
(INITIAL HERE)
I understand that the ultimate responsibility to limit my access to California gambling establishments or participating gambling
facilities or gaming services in the State of California remains mine alone.
(INITIAL HERE)
I understand that disclosure of certain information is necessary to effect my request for self-exclusion.
(INITIAL HERE)
I understand that my information will be added to a statewide exclusion database. Disclosure may also occur, if needed, for the
conduct of an official investigation; or, if ordered by a court of competent jurisdiction.
(INITIAL HERE)
I understand that this self-exclusion request is irrevocable during the time period checked. Removal from a lifetime request will
require the submission of a Self-Exclusion Removal Request form CGCC-CH7-06 (New 05/20).
(INITIAL HERE)
I will not seek to hold the cardroom business licensee or participating gambling facility liable in any way should I enter a gambling establishment or
participating gambling facility or use any of the services or privileges therein despite this exclusion request; and, I agree to indemnify the State of
California, the California Gambling Control Commission, the Bureau of Gambling Control, and the Office of Problem Gambling for any liability
relating to this request. Specifically, I for myself, my heirs, executors, administrators, successors, and assigns, hereby release and forever discharge the
California Gambling Control Commission, the Bureau of Gambling Control, the Office of Problem Gambling, the cardroom business licensee or
participating gambling facility, their agents, employees, officers, and Directors and those with whom they may lawfully share information regarding
this exclusion (collectively, the “Released Parties”) from any and all claims in law or equity that I now have, or may have in the future, against all or
any of the Released Parties arising out of, or by reason of, the performance or non-performance of this self-exclusion request, or any matter relating
thereto. I further agree, in consideration for the Released Parties’ efforts to implement my exclusion, to indemnify and hold harmless the Released
Parties to the fullest extent permitted by law for any and all liabilities, judgments, damages, and expenses of any kind, including reasonable attorneys’
fees, resulting from or in connection with the performance or non-performance of the self-exclusion requested herein.
I declare that all information submitted on or with this self-exclusion form is true, correct, and complete.
PRINTED NAME
SIGNATURE
DATE (MM/DD/YYYY)
NOTARIZATION
OR
WITNESS BY KEY EMPLOYEE
Subscribed and sworn to (or affirmed) before me this
day of
As a Key Employee of
, I affirm that on
(name of gambling establishment
or participating facility)
, 20
,
day of
, 20
,
By
,
I witnessed
(individual’s name)
OR
complete this form and that this person is:
Personally known
Proved to me on the basis of
to me.
satisfactory evidence to be the
Personally known
Proved to me on the basis of
OR
person who appeared before me.
to me.
satisfactory evidence to be the
NOTARY PUBLIC SEAL:
person who appeared before me.
Signature of Notary Public
Signature of Key Employee
My Commission expires on:
Printed Name
Page of 2