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Get Iga Self Exclusion Org Form

IOWA STATEWIDE AND LIFETIME SELF-EXCLUSION FORM ATTACH RECENT PHOTO HERE AND RELEASE OF LIABILITY INFORMATION MUST BE PRINTED OR TYPED Last Name First Name Middle Name Nickname Mailing Address City State Zip Home Phone Number Mobile Phone Number Driver s License Number Issuing State Date of Birth Social Security Number Required Casino Where This Form is Being Filed Casino Player Number I the person identified above request that I be excluded from.

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