Self Exclusion Form

If you wish to auto self exclude, please choose the period of month you wish this to apply for and press "Activate."

Your Login ID
Full Name
Period of Month to be excluded
Email Address

Note: You cannot cancel a self exclusion request. Once it is activated you will be excluded from using Hirose services, and you will be notified by email. We will not consider the self-exclusion period as having commenced until it has been fully implemented and communicated to you.