Specimen Signature Card for Authorized Representative
Page No. Page 1 of 1 Form No. GLDD - 1012 SPECIMEN SIGNATURE CARD FOR AUTHORIZED REPRESENTATIVE Revision No. 3 Effectivity July 12,2023 Date: Name of Supplier: Business Address: PERSONS AUTHORIZED BY SUPPLIER TO SIGN FORMS Please honor and recognize Name Position/Title the following signatures: 1. 2. 1. 2. 1. 2. CERTIFICATION This is to certify that the person/s whose signature/s appears above is/are our authorized representative/s designated to sign Forms for submission to the Gaming Licensing and Development Department (GLDD). We also understand that if the Forms submitted are signed by any other person not included in this list, the same shall not be processed and subsequently returned by GLDD. Approved by: (To be filled up by the Supplier’s CEO or its equivalent) NAME & POSITION DATE (Please Sign over Printed Name)
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