Cancellation of Site Form, ROASD-567, Revision 0

Page No. 1 of 1 Form No. ROASD-567 CANCELLATION OF SITE FORM Revision No. 0 Effectivity Jun. 29, 2026 PART A: GENERAL INSTRUCTIONS 1. Use this form to signify the Company’s intent to cancel existing operating address 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 PAGCOR - 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: Letter request indicating the reason/s for the cancellation of operating site and the intended effectivity date Board Resolution / Director’s Certificate signifying the Company’s decision for voluntary cancellation of its operating site Notarized Undertaking to conduct post-operational activities within 30 days from the approval of the cancellation Updated Lease Agreement (if applicable) Surrender of previously issued Certificate / Accreditation REQUEST FOR CANCELLATION OF OPERATING SITE/S MUST BE SUBMITTED TO PAGCOR-ROASD AT LEAST 30 DAYS PRIOR TO THE EFFECTIVITY DATE OF CANCELLATION PART C. NOTIFICATION DETAILS DATE: NAME OF COMPANY: TYPE OF LICENSE / ACCREDITATION: REASON FOR CANCELLATION: INTENDED DATE OF EFFECTIVITY: OPERATING ADDRESS/ES TO BE CANCELLED: FLOOR AREA 1. 2. 3. 4. 5. (Note: Please use additional sheet/s if the space provided above is not sufficient) REMAINING OPERATING ADDRESS/ES: FLOOR AREA 1. 2. 3. 4. 5. (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