"I am voluntarily requesting exclusion from all Virginia sports betting, casino gaming, and account-based lottery. I also understand that the department will share my information with the Office of Charitable and Regulatory Programs, the Virginia Racing Commission, and all Virginia sports betting permit holders and casino gaming establishments, any of whom may prohibit me from participating in further gaming activities regulated or provided by those entities, including out-of-state sports betting sites or casinos in accordance with the policies of that sports betting permit holder or casino gaming establishment. I agree to notify the department within seven days if my contact information changes. I certify that the information I have provided is true and accurate, and that I have read and understand and agree to the waiver and release included with this request for self-exclusion. I am aware that my digital signature authorizes the department to prohibit me from participating in all account-based lottery games and to direct all holders of sports betting permits and casino gaming establishments in Virginia to restrict my gaming activities. I am further aware that my digital signature authorizes the department to share my information with the Office of Charitable and Regulatory Programs and the Virginia Racing Commission, who may further restrict my gaming activities. In accordance with this request and until such time as the department removes my name from the self-exclusion list under the terms of my request for voluntary self-exclusion, I am aware and agree that during any period of self-exclusion any money obtained by me in violation of the terms of my self-exclusion shall be subject to forfeiture and donated to the Commonwealth's Problem Gambling Treatment and Support Fund."
"I am voluntarily requesting exclusion from all Virginia sports betting, casino gaming, and account-based lottery. In addition, I understand that my information will be shared with the Office of Charitable and Regulatory Programs, the Virginia Racing Commission, and all Virginia sports betting permit holders and casino gaming establishments, any of whom may prohibit me from participating in further gaming activities regulated or provided by those entities, including out-of-state sports betting sites or casinos in accordance with the policies of that sports betting permit holder or casino establishment. I agree to notify the department within seven days if my contact information changes. I certify that the information I have provided is true and accurate, and that I have read and understand and agree to the waiver and release included with this request for self-exclusion. I am aware that my signature authorizes the department to prohibit me from participating in all account-based lottery games and to direct all holders of sports betting permits and casino gaming establishments in Virginia to restrict my gaming activities. I am further aware that my signature authorizes the department to share my information with the Office of Charitable and Regulatory Programs and the Virginia Racing Commission, who may further restrict my gaming activities. In accordance with this request I am aware and agree that any money obtained by me in violation of the terms of my self-exclusion shall be subject to forfeiture and donated to the Commonwealth's Problem Gambling Treatment and Support Fund."
11 Va. Admin. Code § 5-60-20
Statutory Authority: §§ 58.1-4007 and 58.1-4015.1 of the Code of Virginia.