Request for Certification, ROASD-642, Revision-3

Page No. Page 1 of 1 REQUEST FOR CERTIFICATION Form No. ROASD-642 FORM Revision No. 3 Effectivity June 29, 2026  Please use this form to request for Certification on whether a company/entity/individual/website is duly authorized to engage in Internet Gaming Operations.  Only request with correct and complete information as well as proper attachments will be processed.  Processing of request for certification shall only commence upon receipt from our Compliance Monitoring and Enforcement personnel of the site inspection report attesting that the subject company individual/website/address is not engaged in any internet gaming related activities.  Kindly submit one (1) form per request. PART A. DETAILS OF THE REQUEST 1. SUBJECT OF REQUEST 󠅬 DATE :___________________________________________________________ 󠅬 COMPANY NAME :___________________________________________________________ 󠅬 NAME OF INDIVIDUAL :___________________________________________________________ 󠅬 WEBSITE :___________________________________________________________ 󠅬 ADDRESS / LOCATION :___________________________________________________________ ___________________________________________________________ 󠅬󠅬 OTHERS :___________________________________________________________ 2. REASON(S) / PURPOSE(S): PART B. REQUIRED ATTACHMENTS / SUPPORTING DOCUMENTS 1. SECURITIES AND EXCHANGE COMMISSION (SEC) REGISTRATION; 2. LATEST GENERAL INFORMATION SHEET (GIS); 3. ARTICLES OF INCORPORATION (AOI); 4. BY-LAWS; AND 5. ENDORSEMENT FROM THE LOCAL GOVERNMENT UNIT (LGU) WHERE THE COMPANY/BUSINESS IS LOCATED. PART C. DETAILS OF REQUESTOR NAME: COMPANY / ENTITY: DESIGNATION: CONTACT NUMBER: EMAIL ADDRESS: _______________________________________ SIGNATURE OVER PRINTED NAME