OG Form 1174 - Application Form (Form A)

Page No. Page 1 of 1 Offshore Gaming Employment License (OGEL) Form No. OGLD - 1174 APPLICATION FORM (Form A) Rev. No. 5 Effectivity October 17, 2023 Name of Company: Business Address: Authorized Representat ive: Contact Number: NAME DATE OF BIRTH TYPE OF VISA AEP 9(G) VISA VISA VALIDITY CITIZENSHIP POSITION TIN (FIRST NAME-MIDDLE INITIAL-SURNAME) (Ex. July 10, 2020) (For foreign) NUMBER NUMBER (Ex. July 10,2020) TOTAL: INSTRUCTIONS 1. All names should be typed in uppercase 2. Date of birth and visa validity must be encoded in month-date-year (Ex. July 10, 2020) 3. 9G visa number or ACR NO. is indicated at back of Icard/ACR card (Ex. G0000023658) 4. Positions should be involved gaming operations CERTIFICATION This is to certify that: 1. We have validated and have on record the following documents of each of the above listed employees ( LOCAL - PSA certified Birth Certificate, Valid NBI Clearance, TIN, 2x2 picture and specimen signature. FOREIGN - Photocopy of passport from country of origin, Correct and valid work visa or permit, TIN, 2x2 picture and specimen signature) 2. That all information above is true and correct (Page/s 1 to ). Approved by: (To be filled up by the Authorized Representative. Please attach a copy of your valid ID) NAME DATE (Please Sign over Printed Name)