Entain Group - Coral Form - Let's Check in/Time to Talk Leaflet

Shop Details

Please enter the details of the shop in which information was requested

Please search for the shop. If the shop is not listed, please select 'Other Shop (Not Listed)' and manually enter

Other Shop (Not Listed) e.g. Street details, City/Town, Postcode

Shop Number (if provied by colleague on the leaflet)

Please enter your details

Ref number (if provided by colleague on leaflet)

Date of Birth

First name

Last name

Phone Number:

Email Address

Address Line 1

Address Line 2

Town/City

County

Postcode

Date:

Additional Details

Thinking about your betting activity over the last twelve months, please answer the following questions:

Have you ever found yourself in financial difficulties through gambling more than you could afford to lose?

Yes

Have you ever borrowed money or gone into debt to obtain money for gambling?

Yes

Have you gambled money that was supposed to be spent on bills, rent or other commitments?

Yes

Drop files here
or