Application/Renewal for Permit to Hold Gaming Equipment and Gaming Paraphernalia

Page No. Page 1 of 3 APPLICATION / RENEWAL FOR PERMIT Form No. GLDD - 1019 TO HOLD GAMING EQUIPMENT AND Revision No. 4 GAMING PARAPHERNALIA Effectivity February 19, 2024 A. APPLICATION FOR PERMIT TO HOLD GAMING EQUIPMENT AND GAMING PARAPHERNALIA 1. Only Enrolled Suppliers shall b e eligible to apply for a Permit to Hold Gaming Equipment and Gaming Paraphernalia. 2. An application for the Permit to Hold Gaming Equipment and Gaming Paraphernalia shall be on a per transaction basis. B. DIRECTIONS FOR ACCOMPLISHMENT OF THE APPLICATION 1. TYPE or PRINT your answers on the application form. 2. State N/A in response to a question that does not apply to you or if there are no details to disclose in a response to a particular question. 3. Attached additional sheet/s if the space provided on the form is insufficient for your answer. All the pages of the application form, including the additional sheet/s (if any) must be signed by the applicant or its authorized representative providing the information. C. AUTHORIZED REPRESENTATIVE 1. The Applicant must designate an authorized representative responsible for the completion of the application form and certification of all information provided. 2. A board resolution or secretary's certificate must be attached to this application to substantiate the designation of the authorized representative. D. ATTACHMENTS TO THE APPLICATION 1. Duly accomplished SRM Form No. 4 – Specimen Signature Card 2. Registration Certificate issued by any of the following agencies: a. Department of Trade and Industry (DTI); or b. Securities and Exchange Commission (SEC) 3. Articles of Partnership/Corporation and By Laws (if applicable) 4. Certified True Copy of Income Tax Return (ITR) for the previous year (if applicable) 5. Proof of Accreditation from an Operator E. SUBMISSION OF APPLICATION Submit this form together with the required attachments to: Philippine Amusement and Gaming Corporation (PAGCOR) Gaming Licensing and Development Department (GLDD) MET Live Building, Central Business Park 1-A Macapagal Boulevard cor. EDSA Extension, Pasay City 1300 For inquiries you may reach us at: Tel No: ( + 6 3 2 ) 8 5 2 2 - 0299/8522-1357/8522- 1245/8522-1324, local 1600 Email address: [email protected] Hours available: 8:00 AM – 7 PM

Page No. Page 2 of 3 APPLICATION / RENEWAL FOR PERMIT Form No. GLDD - 1019 TO HOLD GAMING EQUIPMENT AND Revision No. 4 GAMING PARAPHERNALIA Effectivity February 19, 2024 NEW RENEWAL STRICTLY CONFIDENTIAL PART A. BASIC INFORMATION 1. Name of Supplier: 2. Certificate of Enrollment No.: 3. Head Office / Business Address: 4. Local Business Address: (if any) 5. Tel. No.: 6. Fax No.: 7. Email Address: 8. Company Website: PART B. AUTHORIZED REPRESENTATIVE 9. Name: 10. Position or Title in the Company (e.g., board of director/secretary etc.) 11. Tel. No.: 12. Fax No.: 13. Mobile No. 14. Email Address Authorized Representative Signature:

Page No. Page 3 of 3 APPLICATION / RENEWAL FOR PERMIT Form No. GLDD - 1019 TO HOLD GAMING EQUIPMENT AND Revision No. 4 GAMING PARAPHERNALIA Effectivity February 19, 2024 STRICTLY CONFIDENTIAL 15. Item/s to be stored Gaming Table Bingo machine or console Playing Cards Chips/Plaques Slot Machine Spare Parts/Accessories Game Conversion Kits Gaming Table Layout Slot Machine Signage Surveillance Equipment Casino Management System for Tables, Slots or Ebingo Gaming Paraphernalia Bingo Flashboard Slot Machine Bingo Paraphernalia Electronic Table Game Terminals Bingo Tickets Electronic Bingo Machine/Terminals Bingo Balls Others 16. Storage Facility Name 17. Storage Facility Address 18. Storage Facility Ownership Owned Leased If LEASED, please provide the following details 19. Name of Lessor 20. Lease Period PART E: DECLARATION I hereby declare that: a. I have obtained all the requisite LGU permits for the operation and maintenance of the storage facility; and b. all information contained herein and, in the documents, submitted are true and correct. Authorized Representative Signature: