Request for Amendment of Gaming License Form, ROASD-1057, Revision-0

Page No. 1 of 1 REQUEST FOR AMENDMENT OF Form No. ROASD-1057 CERTIFICATE FORM Revision No. Effectivity 0 Jun. 29, 2026 PART A: GENERAL INSTRUCTIONS 1. Use this form to request the amendment of an existing license/accreditation registered with PAGCOR 2. Write your answers in block letters. If the information required is not applicable, write “NA” 3. Print your application form and all documentary requirements on an A4-size paper. 4. Original documents must be submitted to the ROASD Office. Applications with incomplete information / requirements will not be accepted. Note: For any inquiries regarding your application, you may contact ROASD through : 8522 0299 local 1188 / 1189 PART B : REQUIRED ATTACHMENTS / SUPPORTING DOCUMENTS This notification form must be accompanied by the following supporting documents: Surrender of previously issued Certificate FOR CHANGE OF COMPANY NAME: Letter request for the change of company name Certified True Copy of amended SEC Registration Certified True Copy of latest General Information Sheet with beneficial owner page Updated BIR Certificate of Registration Updated Mayor’s Permit / Business Permit FOR CORRECTION OF OPERATING ADDRESS: Letter request for the correction of operating address Lease Agreement covering the corrected operating site/s Updated BIR Certificate of Registration (if applicable) Updated Mayor’s Permit / Business Permit (if applicable) Updated Letter of No Objection (for RPP/RPSM applicant, if applicable) PART C. NOTIFICATION DETAILS DATE: NAME OF COMPANY: TYPE OF LICENSE / ACCREDITATION: REASON FOR AMENDMENT: TYPE OF AMENDMENT: CHANGE OF COMPANY NAME CORRECTION OF OPERATING ADDRESS AMENDMENT DETAILS FROM TO (CURRENT COMPANY NAME / OPERATING ADDRESS) (NEW COMPANY NAME / CORRECTED OPERATING ADDRESS) 1. 1. 2. 2. 3. 3. (Note: Please use additional sheet/s if the space provided above is not sufficient) PART D. AUTHORIZED REPRESENTATIVE PRINTED NAME: POSITION TITLE: CONTACT NUMBER: EMAIL ADDRESS: ________________________________________ SIGNATURE OVER PRINTED NAME