Additional / Change of Authorized Representative Form, ROASD-013, Revision 0

Page No. 1 of 1 ADDITIONAL / CHANGE OF Form No. ROASD-13 AUTHORIZED REPRESENTATIVE FORM Revision No. 0 Effectivity Jun. 29, 2026 PART A: GENERAL INSTRUCTIONS 1. Use this form to signify the Company’s intent to add / change the Authorized Representative previously declared 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 the 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 for the addition / change of the Company’s authorized representative 1. Board Resolution appointing the New Authorized Representative Personal Disclosure Sheet (PDS) of the New Authorized Representative PART C. NOTIFICATION DETAILS DATE: NAME OF COMPANY: TYPE OF LICENSE / ACCREDITATION: COMPANY EMAIL ADDRESS: COMPANY CONTACT NUMBER: TYPE OF REQUEST: ADDITIONAL AUTHORIZED REPRESENTATIVE CHANGE OF AUTHORIZED REPRESENTATIVE NEWLY-APPOINTED AUTHORIZED REPRESENTATIVE: NAME OF NEW REPRESENTATIVE: POSITION TITLE: CONTACT NUMBER/S: EMAIL ADDRESS: (Note: Please use additional sheet/s if the space provided above is not sufficient) PART D. CERTIFICATION BY THE CORPORATE SECRETARY PRINTED NAME: POSITION TITLE: CONTACT NUMBER: EMAIL ADDRESS: I hereby certify that the information provided in this Notification Form, together with all supporting documents submitted in connection with the additional and/or change of the Company’s Authorized Representative/s, is true, accurate and correct, and is based on the official records of the Company. ________________________________________ SIGNATURE OVER PRINTED NAME