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DEED OF SELF EXCLUSION
THIS DEED made on Sunday, December 16, 2001 by A. Citizen
Date Of Birth: 02-Oct-1960 of 555 Main Street, Melbourne, 3000 in the State of VICTORIA
WHEREAS:
1. I believe that I have a problem controlling my use of gaming
machines at the gaming venue at:
1) (List Venue), (List suburb)
2) (List Venue), (List suburb)
(It is a good idea to list multiple venues in the areas that you normally frequent.
Some people only need to list one venue and some people need more than twelve. You will
need to be able to name the venues for us to include them in your deed.)
2. I desire to deny myself the right of entry to and to exclude
myself from areas at the Venue/s set aside for gaming purposes only (Restricted Gaming
Areas) and to deny myself the right to use gaming machines at the Venue/s (such exclusions
and denials hereafter called "Self Exclusion").
3. I desire the Australian Hotels Association / Licensed Clubs
Association of Victoria (such Associations hereafter called the "Industry Body"), the
Licensee of the Venue/s and/or their servants or agents to take such action as is necessary
to prevent me from entering the Restricted Gaming Areas and using gaming machines at
the Venue/s and to remove me from such restricted Gaming Areas.
4. I understand that Self Exclusion from Restricted Gaming Areas
at the Venue/s is made voluntarily and does not place any obligation, duty or responsibility
on anyone except myself.
5. I understand and accept that upon signing and lodging this
document with the Industry Body, I become self excluded from the Venue/s and as such
I will not enter any Restricted Gaming Areas or use any gaming machine at the Venue/s
(Self Excluded Person).
6. I understand and accept that upon signing and lodging this
document with the Industry Body, I become ineligible to participate at any Tattersall's
venue in the Advantage programme conducted across Victoria at participating Tattlers'
venues (" Advantage" programme) for the period of self exclusion. I authorize the Industry
Body to forward details of my Self Exclusion to Tattersall's Gaming Pty Ltd ACN 081
925 680 (Tattersall's) and I acknowledge that I shall have no further claim for any
points or entitlements that I have accrued in the Advantage programme.
7. I understand and desire that Self Exclusion from the Venue/s
will remain in force for a minimum period of six (6) months, and will expire on ( A
date is inserted here which reflects the date six months from the period that your deed
is signed).
UNDERTAKINGS
8. I UNDERTAKE that I will, during the Period of Self Exclusion:
a) consider myself as a Self Excluded Person;
b) not withdraw or revoke any undertakings, authorities, release, covenant and/or indemnity
contained in this Deed;
c) not enter the Restricted Gaming Areas at the Venue/s and will not use the gaming
machines at the Venue/s;
d) immediately stop using gaming machines and/or leave the Restricted Gaming Areas at
the Venue/s at the request of the Industry Body, the Licensee of the Venue/s and/or
their servants or agents;
e) seek and continue to seek the assistance and advice of a Problem Gaming Counsellor;
and
f) Not seek to become a member of the Advantage programme.
AUTHORITY
9. I AUTHORISE the Industry Body, the Licensee of the Venue/s
and/or their servants or agents during the Period of Self Exclusion:
a) to ask me to immediately stop using gaming machines and/or to immediately leave the
Restricted Gaming Areas at the Venue/s;
b) if I refuse to immediately stop using gaming machines and/or to immediately leave
the Restricted Gaming Areas at the Venue/s, to take such action as is necessary (including
the use of reasonable force) to remove me from such Restricted Gaming Areas and/or the
Venue/s and to stop me using any gaming machine at the Venue/s; and
c) to take such other action as the Industry Body, the Licensee of the Venue/s and/or
their servants or agents deem necessary (including the use of reasonable force) to prevent
me from entering the Restricted Gaming Areas and from using gaming machines at the Venue/s
and to remove me from such Restricted Gaming Areas and/or the Venue/s.
10. I AUTHORISE the Industry Body to take my photograph.
11. I AUTHORISE the Industry Body to retain a copy of my photograph
and all records relating to my Self Exclusion and to deal with such copies and records
as it sees fit in connection with the Industry Body's Self Exclusion program, including
the anonymous collection of data by the Industry Body. I further authorize the Industry
Body to notify Tattersall's and Tabcorp (Gaming Operators) of my undertaking of Self
Exclusion in order that my name and address may be deleted from their mailing list to
enable them to cancel any entitlements to any of the Gaming Operators promotions.
12. I AUTHORISE the Industry Body, the Licensee of the Venue/s
and/or their servants or agents, within the Period of Self Exclusion, to retain and
display my photograph and name at the Venue/s in an area accessible to Venue staff and
not the general public for the purpose of allowing Venue staff to identify me as a Self
Excluded Person, AND I FURTHER AUTHORISE the use of the photograph for this purpose.
13. I AUTHORISE the Industry Body to advise Tattersall's of the
details of my Self Exclusion, and I AUTHORISE Tattersall's to do all things necessary
to remove me from the Advantage programme.
14. I understand and accept that although I give the above authorities
there is no obligation, duty and/or responsibility on the Industry Body, the Gaming
Operators, the Licensee of the Venue/s and/or their servants or agents to undertake
any or all of the actions or things so authorised.
RELEASE
15. I and my administrators and assigns HEREBY RELEASE AND COVENANT
NOT TO SUE the Industry Body, the Gaming Operators, the Licensee of the Venue/s, their
nominees, servants, agents, contractors, and the legal personal representatives of any
such persons (the Released Persons) from all actions, suits, claims and demands whatsoever
which, but for this document, could now or hereafter be asserted brought or made by
me, or by anyone on my behalf, arising from any damage or injury or otherwise caused
directly or indirectly as a result of any act, default or omission of the Released Persons
in relation to this Self Exclusion, including but not limited to:
a) the display, keeping and dissemination of photographs and records relating to my
Self Exclusion;
b) any interviews with me relating to Self Exclusion;
c) preventing me (including the use of reasonable force) from entering the Restricted
Gaming Areas of the Venue/s and/or the Venue/s, from using gaming machines at the Venue/s,
removing me from Restricted Gaming Areas and/or the Venue/s, and stopping me using gaming
machines at the Venue/s; and,
d) wholly or in part failing to act upon or respond to my desire for and my undertakings
and/or authorities in respect of my Self Exclusion.
16. I accept that the Industry Body, the Licensee of the Venue/s,
their nominees, servants or agents, contractors and/or legal personal representatives
may plead this release and covenant not to sue as an absolute bar to any and all actions,
suits, claims and demands made by me my administrators and assigns or on my behalf whether
made now, proceeding, or hereafter arising directly or indirectly in any way whatsoever
out of my Self Exclusion.
INDEMNITY
17. I and my administrators and assigns now and will at all times
in the future INDEMNIFY AND KEEP INDEMNIFIED the Industry Body, the Gaming Operators,
the Licensee of the Venue/s, their servants or agents, nominees, contractors, and the
legal personal representatives of such persons (the Indemnified Persons) against all
actions, liabilities, proceedings, losses, claims, damages, costs and expenses which
the Indemnified Persons may suffer, incur or sustain in connection with or arising directly
or indirectly from any act, default or omission by or on behalf of the Indemnified Persons
in relation to my Self Exclusion.
ACKNOWLEDGMENTS
18. I ACKNOWLEDGE THAT:
a) the contents of this document have been read to me by the Industry Body at my Self
Exclusion interview held on Sunday, April 16, 2003 ;
b) I understand and accept the effect, obligations, duties and/or responsibilities on
me and my administrators and assigns created by this document, including the undertakings,
authorities, release, covenant, indemnity and acknowledgments;
c) the Industry Body, the Gaming Operators, the Licensee of the Venue/s and/or their
servants or agents make no assurances to me of confidentiality in respect to any matter
connected with my Self Exclusion, including the display of my photograph and name and/or
the keeping and/or dissemination of records and any other information relating to my
Self Exclusion;
d) my Self Exclusion will remain in force and will not be withdrawn during the Period
of Self Exclusion;
e) the Self Exclusion process is entirely voluntary involving voluntary undertakings
by me (but which are enforceable against me) and is not a contract and does not require
any action or responsibility by and in no way binds the Industry Body, the Gaming Operators,
the Licensee of the Venue/s, their nominees, servants or agents, contractors and/or
legal personal representatives;
f) it is not my intention to create any legal duty, obligation or responsibility on
the Industry Body, the Gaming Operators, the Licensee of the Venue/s and/or their nominees,
servants or agents, contractors and/or legal personal representatives;
g) Tattersall's will be advised of my undertakings contained in this Deed and that Tattersall's
shall be at liberty to forthwith remove me from future participation in the Advantage
programme;
h) I hereby forgo any rights whatsoever to any points or entitlements that I have accrued
at any time by participation in the Advantage programme and that I have no future claims
against Tattersall's or the venues or any person for any such points or entitlements;
and
i) Tattersall's shall be at liberty to make a gratuitous payment to me in respect of
any rights or entitlements that I have accrued by participation in the Advantage programme,
and that any such payments is totally at the discretion of Tattersall's and that I shall
have no right to demand any payment whatsoever in respect of my participation in the
Advantage programme.
REVOCATION AND TERMINATION
19. Notwithstanding paragraphs 6 and 7 above, I may revoke this
Self Exclusion but only:
a) after the expiration of a minimum period of six (6) months from the commencement
of the Period of Self Exclusion;
b) by arranging and attending another interview with the Industry Body;
c) by producing written evidence that I have received counselling from a qualified Problem
Gaming Counsellor in respect of revocation of Self Exclusion; and
d) after signing and lodging with the Industry Body the Deed of Revocation of Self Exclusion.
20. At the expiration of the Period of Self Exclusion or upon
revocation in accordance with paragraph 17 above, my Self Exclusion shall be at an end
and I may thereafter enter Restricted Gaming Areas and use the gaming machines at the
Venue/s.
EXECUTED AS A DEED POLL
Signed, Sealed and Delivered by me on
) the Wednesday, November 7, 2001
) at Melbourne ) ..........................................................
Witnessed by: .............................................................
Name of Witness: .....................
Address of Witness: ..................
CERTIFICATION OF REPRESENTOR
I,...................................................... of ................................................................,
hereby certify that I have read and explained the contents of this Deed to .........................................................
on (date of interview).
Signed: .............................................
If you would like more information on Self Exclusion within the
State of Victoria, or would like to contact the AHA to arrange an interview for self
exclusion, visit the AHA website, or contact any Self Exclusion Officer at the AHA
on (03) 9822 0900 to arrange an interview time.
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