Rule 13-3-10.2 - Request for Self-Exclusion(a) Any person may request self-exclusion pursuant to these regulations by appearing personally at any office of the Mississippi Gaming Commission where he or she shall: 1. Present valid identification credentials containing: i. His or her signature; andii. Either a photograph or a general physical description;2. Be photographed by the Commission; and3. Submit a completed Request for Self-Exclusion form; and4. Turn over to the Commission all player club cards and similar items issued by any casinos to the person for purposes of gambling.(b) The Request for Self-Exclusion shall be on a form prescribed by the Commission, and shall be available at all licensed casinos and at any office of the Mississippi Gaming Commission.(c) The Request for Self-Exclusion form shall include:1. The following identifying information concerning the person submitting the self-exclusion request: i. Name, including any aliases or nicknames;iii. Address of current residence;iv. Telephone number of current residence; v. Social Security number, if such information is voluntarily provided by the person requesting self-exclusion;vi. A physical description of the person, including height, weight, gender, hair color, eye color and any other physical characteristic that may assist in the identification of the person; 2. The length of the self-exclusion period requested by the person, which may be for any length of time up to lifetime, but in no event for less than five years.3. A waiver and release that shall be in the following form: "I hereby release and hold the State of Mississippi, the Mississippi Gaming Commission and its employees, and all casinos and their affiliated companies, employees, officers and agents harmless from any claim by me or any third party for any harm, monetary or otherwise, which may arise out of or by reason of any act or omission relating to the request for self-exclusion or maintenance or enforcement of the self-exclusion list, including, but not limited to, the forfeiture of any money or thing of value obtained by me from, or owed to me by, a casino as a result of wagers made by me while on the self-exclusion list."4. The signature of the person submitting the Request for Self-Exclusion indicating acknowledgment of the following statement: "Because I am a problem gambler, I am voluntarily requesting exclusion from the entire premises of all Mississippi casinos, including gaming premises, restaurants, and hotels, and from the issuance of gaming credit, check-cashing privileges, receipt of direct-marketing and promotional materials regarding gaming opportunities, and collection of any winnings or recovery of any losses during the exclusionary period. I understand that no further points, rewards or benefits may be accumulated or redeemed from the player recognition programs I have participated in. I understand that this self-exclusion request does not release me from any debts incurred prior to or during the self-exclusion period. I understand that during the self-exclusion period, any money or thing of value obtained by me from, or owed to me by, a casino as a result of wagers made by me while on the self-exclusion list shall be subject to forfeiture to the Mississippi Gaming Commission. I hereby consent to having this form, my photograph and identifying information disseminated to necessary casino personnel to identify me should I attempt to return to any casino, and further consent to having said information disclosed to casino affiliated companies outside of Mississippi and that I may be excluded from those casinos without further action on my part. I likewise acknowledge that my self-exclusion information may be forwarded by the Mississippi Gaming Commission to the Louisiana and/or Choctaw Gaming Commissions for dissemination to casinos in those jurisdictions, such that I may be self-excluded from those casinos. I acknowledge that for my request of self-exclusion to be truly effective, I must exercise self-restraint and shall not attempt to enter the premises of any casino or ask any casino employee to assist me with any of the services or privileges, which are the subject of this request. I acknowledge that I am hereby banned and forbidden from entering the premises of any casino and that if I am found anywhere on the premises of a Mississippi casino, I will immediately be ejected, and, within the discretion of the casino, may be arrested and prosecuted for criminal trespass pursuant to Miss. Code Ann. 97-17-97; and my continued non-cooperation or attempt to breach my self-exclusion may result in placement by the Commission on the involuntary exclusion list. I certify that the information that I have provided herein is true and accurate, and that I have read, understand and agree to the waiver and release above."
5. An indication of the type of identification credentials examined containing the signature of the person requesting self-exclusion, and whether said credentials included a photograph or just a general physical description of the person; and6. The signature of a Commission employee authorized to accept such request, indicating that the signature of the person on the Request for Self-Exclusion appears to agree with that contained on his or her identification credentials, and that the photograph or physical description of the person contained on his identification credentials appears to agree with his or her actual appearance.(d) The request for self-exclusion may be made only by the individual for whom exclusion would apply, and not by any other person. Miss. Code Ann. § 75-76-33