FORM 1021

Page No. Page 1 of 2 APPLICATION FOR REGISTRATION OF Form No. GLDD - 1021 TRAINERS Revision No. 3 Effectivity September 25, 2024 (To be accomplished by the Licensee) GENERAL INSTRUCTIONS 1. Please type or print legibly. Use black pen/ink only. 2. A complete application includes:  Certified list of trainers with the course/program/modules being handled  Certification of non-teaching staff with their corresponding positions. Each of the following per trainer:  Duly accomplished application form  Certificate of Employment (with present employer) duly signed by the head of HR  Certificate of Related Trainings/Seminars Attended (if applicable)  Photocopy of PAGCOR-issued Gaming Employment License 3. All submitted documents must be compiled in a folder with proper indexes and labeling. 4. Application with incomplete requirements shall not be accepted. COMPLETE NAME OF TRAINING FACILITY COMPLETE ADDRESS (LOCATION OF FACILITY)

Page No. Page 2 of 2 APPLICATION FOR REGISTRATION OF Form No. GLDD - 1021 TRAINERS Revision No. 3 Effectivity September 25, 2024 LIST OF TRAINERS (You may provide additional sheets if necessary.) Name of Trainer Course/Programs/Module Handled NAME OF HEAD POSITION/DESIGNATION SIGNATURE