Register Exclusion

Name

First names

Date of birth (DD/MM/YYYY)

Place of birth

Street

Number

P.O. Box

Postal code

Municipality

Country

Nationality

Number identity document

Type of identity document

Attach a scan of your identity document (max. 10MB)

(max. 5MB)

E-mail

Confirm e-mail

E-mail of reference (optional)

Confirm e-mail of reference

I, undersigned, apply for an access ban for casinos, slot machine arcades and for betting shops (online and offline).