READY TO TAKE A BREAK?

Before you begin, please gather the following items:

• A copy of your driver’s license

• A recent photo of yourself (not your driver’s license photo)

• Access to a Notary Public (such as at a bank, tag agency, or mailing center)

• A quiet place where you can focus

Go through each section on the form and fill in your information. You’ll need to:

• Write your full legal name

• List any nicknames or aliases

• Provide your birth date, address, and contact info

• Fill out your physical description (height, weight, hair, eyes, etc.)

Take your time. It’s okay to pause and come back to it.

You'll see boxes for 1 year, 3 years, 5 years, or 10 years.
Check the box that feels right for you. Please note that once you are added to the self-exclusion list, the timeframe cannot be changed.

There are several statements that explain:

• What it means to be self-excluded

• What casinos will do

• What your responsibilities are

After reading each one, write your initials on the line. If you're not sure about something, call OAPGG: 405-801-3329.

Make sure you have:

• A copy of your driver’s license

• A separate, recent photo of yourself (selfies are okay)

• Your completed form

Bring the form, photo, and ID to a Notary Public.

• You must sign the form in front of them

• The notary will also fill out part of the form and stamp it

Make sure the date you sign is the same as the notary’s date.

You can also bring these items to be notarized at the OAPGG office in Norman (501 E Alameda, Suite E, Norman, OK 73071). Please call ahead to verify that this service is available (405-801-3329).

Once everything is signed and ready, mail the form, photo, and ID copy to:

Oklahoma Association on Problem Gambling & Gaming
501 E. Alameda St. Suite E
Norman, OK 73071