OG Form 1058 - Revised Transfer of Site Notification Form

TRANSFER OF SITE Page No. 1 of 1 Form No. OGLD-1058 Revision No. 5 NOTIFICATION FORM Effectivity Aug. 9, 2023 Use this form to signify intent to vacate previously registered address with PAGCOR and move to another operating site/s. Only requests with correct, complete information and documentary requirements will be processed. Applications with incorrect and/or incomplete information/requirements will be returned. ALL OPERATING SITES/ ADDRESSES ARE SUBJECT TO INSPECTION. PART A. COMPANY INFORMATION NAME OF APPLICANT: TYPE OF LICENSE / AUTHORIZATION: PART B. TRANSFER OF OPERATING SITE REQUEST/S OPERATING ADDRESS COMPANY NAME FROM TO (Note: Please use additional sheet/s if the space provided above is not sufficient) Required Attachments: LONO (if necessary) Lease Agreement of New Operating Site/s PART C. AUTHORIZED REPRESENTATIVE INFORMATION (to be filled out by Authorized Representative) NAME: POSITION IN THE COMPANY: CONTACT NUMBER: EMAIL ADDRESS: ________________________________________ SIGNATURE OVER PRINTED NAME PART D. ACTION TAKEN (to be filled by OGLD) PART E. ENDORSEMENT TO RMD Payment Cleared by FOCAS RECEIVED BY: Complete Supporting Documents OLS-OGLD Ref. No.: _________________ PROCESSED BY: CHECKED & VERIFIED BY: Printed Name: Position: Date: __________________ __________________ (Signature over printed name) (Signature over printed name)