Request For Voluntary Exclusion From Finger Lakes Gaming & Racetrack Form

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08/2014
REQUEST FOR VOLUNTARY EXCLUSION FROM
FINGER LAKES GAMING & RACETRACK
This form is to be completed by a patron requesting to be excluded from gaming activities at Finger Lakes Gaming &
Racetrack pursuant to NYS 2836-19.6. All information contained on this form is confidential.
PLEASE PRINT OR TYPE THE ANSWERS TO THE FOLLOWING QUESTIONS IN THE SPACES PROVIDED
1. NAME: _____________________________________________________________________________
LAST (INCLUDE SR., JR., ETC., IF APPLICABLE)
FIRST
MIDDLE
2. DO YOU USE ANY OTHER NAME OR NAMES?
YES
NO
. IF YES, LIST THE ADDITIONAL
NAME(S) BELOW (INCLUDE MAIDEN NAME, ALIASES, NICKNAMES, OR ANY OTHER NAME):
3. HOME ADDRESS: ___________________________________________________________________
NUMBER AND STREET
APT#
________________________________________________________________________
CITY
STATE
ZIP CODE
4. HOME TELEPHONE NUMBER: ________________________________________________________
(AREA CODE)
NUMBER
: _________________________________________
5. SOCIAL SECURITY NUMBER
6. PLAYER EXTRAS NUMBER: _________________________________________________
7. DRIVER’S LICENSE: STATE: _____ MOTORIST ID #_______________________________
8. DATE OF BIRTH: __________________/_____________/_________________
MONTH
DAY
YEAR
9. HEIGHT: ______________________
10. WEIGHT: ____________________
FT-IN
LBS
PLEASE CHECK APPROPRIATE BOX:
11. GENDER:
(M) MALE
12. HAIR COLOR:
13. EYE COLOR:
(F) FEMALE
(BK) BLACK
(BK) BLACK
(BR) BROWN
(BR) BROWN
(BD) BLOND
(HZ) HAZEL
(RD) RED
(BL) BLUE
(GY) GRAY
(GY) GRAY
(WH) WHITE
(GR) GREEN
(BA) BALD
(OT) OTHER_______
(OT) OTHER_________
14. OTHER DISTINGUISHING PHYSICAL CHARACTERISITICS: _____________________________
15. SELF-EXCLUSION PERIOD* (Choose One)
ONE YEAR
THREE YEARS
FIVE YEARS
*note: exclusion is enforced until period chosen has expired AND a Reinstatement Form has been signed and filed with the
Security Department.
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