Self-exclusion Form

* = Required field

Name *

Enter your postcode including any spaces

Tick here to enter your address manually

Address 1 *

Address 2

Address 3

Town *

Postcode *

Email address *

Telephone Number

Please tick below your chosen self-exclusion period: *

6 months
1 year
2 years
5 years

Submitting this request enters you into the self-exclusion scheme as detailed in the Shaftesbury Problem Gambling and Self-Exclusion policy.

If you would like to enter our lottery again after this period you can call our helpline on 01628 956638.

For friendly and helpful advice from trained counsellors call the National Gambling Helpline on 0808 8020 133. The helpline operates 24 hours a day, 7 days a week, 365 days a year.

Sometimes just telling someone about your problem can be a relief and it is the first step towards dealing with your problem. You can also visit the GambleAware website gambleaware.org for more information and advice.

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Self-Exclusion form