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 Macular Society 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 201 282.

Please remember for friendly and helpful advice from trained counsellor’s call the National Gambling Helpline on 0800 8020133 or visit the GambleAware website www.begambleaware.org.

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