Application for accoumt Freeze or Colling Off – Self Exclusion South Africa

Signature ID/Passport Number

Insert Operator

Name of Online Operator, e.g., Betway or Hollywoodbets or BettaBet

Name

First

Last

Applicant Full Name

ID/Passport Number

Contact Number

Account Username/Mobile Number

Applicant Account Details

I hereby formally authorize the South African Responsible Gambling Foundation (SARGF) and its authorised staff to act on my behalf.

I request that you immediately freeze my account, restrict access, and implement a temporary cool-off period on all my profiles associated with your platform. This restriction must remain in place while my formal national self-exclusion application is being processed by the Provincial Gambling Board.