OG Form 222 - Revised Revival of Gaming License Form

To be filled out by OGLD OLS-OGLD REF NO.: DATE: REQUEST FOR REVIVAL OF Page No. Form No. 1 of 1 OGLD - 222 GAMING LICENSE FORM Revision No. Effectivity 2 May 5, 2022 Use this form to signify intent to apply for the REVIVAL OF LICENSE of those licensees who have been cancelled due to pandemic-related concerns or due to failure to secure Authority to Resume Operations within one (1) year period reckoning from respective dates of license cancellation. Only requests with correct, complete information and documentary requirements will be processed. Applications with incorrect and/or incomplete information/requirements will be returned. TYPE OF AMENDMENT: Revival Type 1 (License has not Expired) Revival Type 2 (License has Expired) PART A. COMPANY INFORMATION NAME OF POGO: TYPE OF LICENSE: PRIMARY OFFICE ADDRESS: (Please use additional sheet/s if the space provided is not sufficient) VALIDITY DATE OF LICENSE: PART B. AUTHORIZED REPRESENTATIVE INFORMATION (to be filled out by Authorized Representative) NAME: POSITION IN THE COMPANY: CONTACT NUMBER: EMAIL ADDRESS: PART C. DOCUMENTARY REQUIREMENTS 1. Letter of intent to revive Offshore Gaming License addressed to the Chairman and CEO of PAGCOR; 2. Request for Revival of Gaming License Form 3. Proof of payment of the license revival fee / renewal fee; 4. Proof of full payment of arrears or at least 50% of its arrears, with a proposal for the restructuring of the remaining amount to be paid on top of its monthly regulatory fee; 5. Proof of payment of all outstanding penalties; 6. Proof of replenishment of performance bond; 7. BIR Certificate of Registration; 8. Additional Requirements for Revival Type 2:  Completely filled out Application Form for Renewal  Latest General Information Sheet (GIS)  Updated Notarized Personal Disclosure Statements (PDS) of Authorized Representative, President, Corporate Secretary and Treasurer of the company  If there are material changes in the corporate structure: a. New Organizational Chart indicating names of the person/s occupying the position/s b. Board Resolution or Secretary’s Certificate appointing new Authorized Representative c. Specimen Signature Card of new Authorized Representative  Letter of No Objection (if applicable)  Lease Agreement / Proof of Ownership of Operating Site (if applicable) PART D. DECLARATION By signing below, I declare that I am duly authorized to submit the application on behalf of the corporation; that the information contained herein and which accompanies this application is true and accurate to the best of my knowledge and understanding; and the company agree to abide by the provisions of the implementing guidelines on the cancellation of Offshore Gaming Licenses with Right to Revive which will be the law governing the applicant’s relationship with PAGCOR. _______________________________________ SIGNATURE OVER PRINTED NAME