Exclusion forms

The following is a list of gambling-related exclusion forms.

If you need help completing a form, contact the Office of Liquor and Gaming Regulation (OLGR) for assistance.

Self-exclusion forms

Form 3A: Self-exclusion notice

Individuals seeking to self-exclude from a venue or gambling activity must complete Form 3A and give it to the gambling provider/s.

Form 3B: Self-exclusion order

On receipt of Form 3A, the gambling provider completes Form 3B and gives it to the individual as an acknowledgement of their self-exclusion.

Form 3C: Revocation notice - self-exclusion order

Individuals seeking to cancel self-exclusion must complete Form 3C and lodge it with the gambling provider.

Form 3C can only be lodged within the initial 24-hour cooling-off period after submitting Form 3A, or 1 year after the exclusion was lodged by the individual.

Venue-initiated exclusion forms

Form 3D: Exclusion direction

The gambling provider completes Form 3D and gives it to the individual to exclude them from a venue or gambling activity  (also refer to Form 3I).

Form 3E: Application to revoke exclusion direction

Individuals seeking to cancel venue-initiated exclusion must complete Form 3E and lodge it with the gambling provider.

Form 3E may only be lodged 1 year after the exclusion commenced. Only 1 application may be lodged by a patron in any 12-month period  (also refer to Form 3F and Form 3J).

Form 3F: Revocation notice - exclusion direction

On receipt of Form 3E, the gambling provider completes Form 3F and gives it to the individual to confirm the cancellation of the venue-initiated exclusion -  for cancellations only (also refer to Form 3J).

Form 3I: Information notice - exclusion direction

The gambling provider completes Form 3I and gives it to the individual with Form 3D, to provide information about why the exclusion has been issued (also refer to Form 3D).

Form 3J: Information notice - refusal to revoke an exclusion direction

On receipt of Form 3E, the gambling provider completes Form 3J and gives it to the individual to provide information about why the gambling provider has refused to cancel the exclusion - for refusals only (also refer to Form 3F).

Miscellaneous exclusion forms

Form 3G: Register of excluded persons

The gambling provider records the details of individuals who have been excluded from their venue or from gambling activities at the venue on Form 3G.

Form 3H: Notice of contravention of self-exclusion order/exclusion direction

The gambling provider completes Form 3H if an individual breaches a self-exclusion order or exclusion direction, and lodges it with the Office of Liquor and Gaming Regulation (OLGR).

Form 3R: Report on excluded persons

The gambling provider completes Form 3R and lodges it with OLGR, who must receive it no later than 14 days after 30 June and 31 December each year.