AUTHORIZED SIGNATORY AND CONTACT INFORMATION
Page No. Page 1 of 2 AUTHORIZED SIGNATORY WITH SPECIMEN SIGNATURE Form No. EGLD-1310 AND CONTACT INFORMATION Revision. No. 5 Effectivity February 13, 2024 LICENSED OPERATORS SERVICE PROVIDERS LICENSED CASINOS Corporation Name : _____________________________________________________ Registered / Main Office Address : _____________________________________________________ Trade Name / Gaming Venue Name : _____________________________________________________ Game Offering : _____________________________________________________ CONTACT INFORMATION Telephone / Mobile Nos.: Official E-mail Address/es: (1) (1) (2) (2) AUTHORIZED REPRESENTATIVES AND SIGNATORIES For multiple gaming venues with different authorized/alternate signatories and representatives per gaming venue, pls use Schedule 1 (Put N/A if not applicable) 1. Authorized / Alternate Signatory/ies Name Position Specimen Signature 2. Authorized Signatory/ies (EG Forms) Name Position Specimen Signature 3. Authorized Person/s to Transact with PAGCOR Name Position Contact / Mobile Nos. I have read, understood, and consented to PAGCOR’s Privacy Notice and Privacy Policy. I hereby certify that the foregoing Officers of the Corporation as indicated above are authorized to act, sign, execute, and/or deliver any and all documents, instruments, for and in behalf of the Corporation. IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of ______________ at ___________. ____________________________ CORPORATE SECRETARY SUBSCRIBED AND SWORN to before me this __________ day of _________________ by affiant who exhibited to me his/her ______________________. (Valid Government-issued ID) Doc No.__________ Page No._________ Book No._________ Series of _________
Page No. Page 2 of 2 AUTHORIZED SIGNATORY WITH SPECIMEN SIGNATURE Form No. EGLD-1310 AND CONTACT INFORMATION Revision. No. 5 Effectivity February 13, 2024 Schedule 1 Corporation Name : ______________________________________________________________ LIST OF GAMING VENUES Additionally, fill-up this form for Operators with multiple gaming venues which have designated various authorized signatories and/or representatives for each gaming venue: Gaming Venue Authorized Authorized to Authorized Signatories Signatories Contact Name and Venue Transact with (Correspondences) (Operational Request/ Information Address EG Form) PAGCOR 1. Name/Position: Name/Position: Name/Position: Tel / Mobile Nos.: Specimen Signature: Specimen Signature: Email: 2. Name/Position: Name/Position: Name/Position: Tel / Mobile Nos.: Specimen Signature: Specimen Signature: Email: 3. Name/Position: Name/Position: Name/Position: Tel / Mobile Nos.: Specimen Signature: Specimen Signature: Email: 4. Name/Position: Name/Position: Name/Position: Tel / Mobile Nos.: Specimen Signature: Specimen Signature: Email: 5. Name/Position: Name/Position: Name/Position: Tel / Mobile Nos.: Specimen Signature: Specimen Signature: Email: *repeatedly use this page for additional gaming venues
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