OG Form 1056 - Revised Additional Site / Address Notification Form

Page No. 1 of 1 ADDITIONAL SITE / ADDRESS Form No. OGLD-1056 NOTIFICATION FORM Revision No. 5 Effectivity Aug. 9, 2023 Use this form to signify intent to apply for operating site/s in addition to the previously registered address with PAGCOR. Only requests with correct, complete information and documentary requirements will be processed. Applications with incorrect and/or incomplete information/requirements will be returned. ALL ADDITIONAL OPERATING SITES/ ADDRESSES ARE SUBJECT TO INSPECTION PART A. COMPANY INFORMATION NAME OF APPLICANT: TYPE OF AUTHORIZATION: *FOR AUTHORIZED PROVIDER, KINDLY INDICATE NAME OF LICENSEE: PART B. ADDITIONAL OPERATING SITE REQUEST/S B.1 EXISTING ADDRESS/ES: FLOOR AREA 1. 2. 3. 4. (Note: Please use additional sheet/s if the space provided above is not sufficient) B.2 ADDITIONAL ADDRESS/ES: FLOOR AREA 1. 2. 3. 4. (Note: Please use additional sheet/s if the space provided above is not sufficient) Required Attachments: LONO (if necessary) Lease Agreement of New Operating Site/s PART C. AUTHORIZED REPRESENTATIVE INFORMATION (to be filled out by Authorized Representative) NAME: POSITION IN THE COMPANY: CONTACT NUMBER: EMAIL ADDRESS: ________________________________________ SIGNATURE OVER PRINTED NAME PART D. ACTION TAKEN (to be filled by OGLD) PART E. ENDORSEMENT TO RMD Payment Cleared by FOCAS RECEIVED BY: Complete Supporting Documents OLS-OGLD Ref. No.: ________________ PROCESSED BY: CHECKED & VERIFIED BY: Printed Name: Position: Date: __________________ __________________ (Signature over printed name) (Signature over printed name)