1.5 REQUEST FOR EXTENSION OF APPLICATION FORM

Page No. Page 1 of 2 REQUEST FOR EXTENSION OF Form No. EGLD - 392 APPLICATION FORM Rev. No. 1 Remote Games Effectivity July 17, 2024 EG Form No. 4 EGLD Reference No.: __________________ Use this form if the Operator intends to request to extend the period to comply with the regulatory requirements. Type or print the needed information on the spaces provided. Submit this form on or before the expiration date of the grace period to comply with regulatory requirements or with the preceding application for extension together with the corresponding Extension Fee. Please use the Payment Processing Request Form (EG Form No. 2) for payment of the Extension Fee. SECTION A: DETAILS OF THE APPLICANT / OPERATOR Name of Operator / Applicant: _____________________________________________________________ (As reflected in the gaming license) Gaming Venue: ________________________________________________________________________ License No. (as applicable) : _______________ GL Validity (as applicable): ________________________ Game Offering: _________________________________ Brand(s): _______________________________ Service Provider(s): _____________________________________________________________________ SECTION B: REQUEST DETAILS (TO BE FILLED-UP BY THE APPLICANT / OPERATOR) Extension Applied for:  Initial  Additional ____ (nth) no. of application Extension applied for (indicate type of application):  New License Application for New Gaming Venue  1-year grace period to commence of gaming venue operations  Renewal of Gaming License  Application for Amendment of Gaming License due to Change in Operator  Temporary Suspension of Operations  Others: _______________________________ Reference: EGLD Reference no.: _________________ Date due for compliance: ________________ Extension period: ________________ - _________________ No. of days: ________________ From To Extension Fee: Date Paid: ________________ Amount paid: _______________ OR Number: __________________ By signing below, we signify our intention to extend the validity of the application as indicated above and this is accompanied by duly accomplished EG Form No. 2 and copy of Official Receipt/bank-validated deposit slip as proof of payment of extension fee. Printed Name: _____________________________________ Signature: _______________________ (Authorized Representative) Position Title: ______________________________________ Date: _________________________

Page No. Page 2 of 2 REQUEST FOR EXTENSION OF Form No. EGLD - 392 APPLICATION FORM Rev. No. 1 Remote Games Effectivity July 17, 2024 EGLD Reference No.: __________________ SECTION C: SUBMISSION INSTRUCTIONS Once Section A and B are completed, please submit/mail/e-mail this form to EGLD together with supporting documents to the address/e-mail address indicated below: Electronic Gaming Licensing Department Philippine Amusement and Gaming Corporation 10th Floor MET LIVE BUILDING Central Business Park 1-A Macapagal Boulevard cor. EDSA Extension, Pasay City 1300 Tel Nos.: (+632) 8522-0299 / 8521-1542 loc. 1561 E-mail addresses: [email protected] (Applications for License or Commencement of Operations) [email protected] (Temporary Suspension of Operations) SECTION D: ACTION TAKEN (TO BE FILLED UP BY EGLD) Request for Extension of Application is: 1.  RETURNED due to incomplete information / non-payment of Extension Fee ____ Incomplete information ____ Non-payment of Extension Fee ____ Not qualified to apply for Request for extension 2.  RECEIVED FOR PROCESSING: By: Printed Name: _______________________________ Signature: ____________________ Position Title: _______________________________ Date: ____________________ 3.  RECOMMENDATION FOR APPROVAL: By: Printed Name: _______________________________ Signature: ____________________ Position Title: _______________________________ Date: ____________________ Approved by : _________________________________ Assistant Vice President