SAMPLE LETTER REQUESTING HEARING
FOR REMOVAL OF NAME
FROM THE SELF-EXCLUSION LIST
Your Return Address
Your Telephone Number
Louisiana Gaming Control Board
Administrative Hearing Office
P. O. Box 4096
Baton Rouge, LA 70821
Dear Docket Clerk:
My name is ___________________________ and, pursuant to LAC 42:III.304(A), I had my
Name placed on the list of persons who are to be excluded or ejected from all casino gaming
Establishments licensed or operating pursuant to Chapters 4, 5, and 7 of the Louisiana Gaming
Control Law, R.S. 27:1 et seq. My inclusion on the List became effective on ___________________
More than five years have elapsed since that date and I now desire to have my name removed
from the Self-Exclusion List. Accordingly, I am hereby requesting a hearing before the Board Hearing
Officer to have my name removed from the List. The specific reasons why I wish to be removed from
the Self-Exclusion List are as follows: [List of Reasons].
Pursuant to LAC 42:III.304(G), please find enclosed a written recommendation from (Dr., Mr.,
Ms., etc.) ______________________________, a qualified mental health professional, stating my
capacity to participate in gaming activities without adverse risks or consequences.
Thank you for your assistance with this matter.