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RG Form 3 Page No. Page 1 of 1 FAMILY EXCLUSION APPLICATION Form No. GLDD-890 FORM Revision No. 6 Effectivity August 24, 2026 NEW APPLICATION RE-APPLICATION USE BLOCK LETTERS AND WRITE LEGIBLY INFORMATION ON APPLICANT (family member making request) (Family Name) (First Name) (Middle Name) ID Presented ID No: Date of Birth Gender Relationship Parent Child Spouse Civil Status Nationality Male Female M M D D Y Y Y Y Block / House No. Floor / Unit No., Bldg. Street Village / Subdivision City Province Landline Mobile Email Address INFORMATION ON RESPONDENT (person to be excluded) (Family Name) (First Name) (Middle Name) ID Presented ID No: Date of Birth Gender Civil Status Nationality Male Female M M D D Y Y Y Y Block / House No. Floor / Unit No., Bldg. Street Village / Subdivision City Province Landline Mobile Email Address Gaming establishment e-Games e-Bingo Sports Betting visited regularly: Poker Clubs Casino, pls. specify Requirements: (Please note that application with incomplete requirements may not be processed) 1. Photocopies of supporting documents, as applicable If applicant is the parent: If applicant is the spouse: If applicant is the child: - Government photo ID of - Government photo ID of - Government photo ID of respondent with signature and respondent with signature and respondent with signature and birthdate birthdate birthdate - Birth certificate of respondent - Marriage contract/certificate - Government ID or school ID with 2x2 - Government photo ID of - Government photo ID of photo of applicant with signature Photo applicant with signature and applicant with signature and - Birth certificate of applicant birthdate birthdate 2. Two (2) 2x2 colored photo of person requested to be excluded - Must be clear - Taken within the last 6 months prior to application - Full-face view directly facing the camera - No facial accessory (hat, glasses, facemask, etc.) 3. If non-personal submission, selfie or video call is required for confirmation TERMS AND CONDITIONS I understand the content and purpose of this Exclusion application and that the effect of this application is that an Exclusion Order will be enforced which shall exclude my relative from entering all gaming establishments and sites operated and licensed / regulated by PAGCOR. I understand that my application for Family-Exclusion will stay in force for a period of: Six (6) months One (1) year Three (3) years I understand that PAGCOR will provide my relative’s name and particulars to all gaming establishments operated and regulated by PAGCOR for the purpose of banning from playing. I declare that the information provided in this application are true and correct. I declare that I will hold PAGCOR harmless from any claim for damages that may be brought against PAGCOR by my excluded relative in any proceeding in relation to this Exclusion Order. I am aware that my relative (respondent) shall not be eligible to collect any winnings or recover losses resulting from any gaming activity, while his/her exclusion period is in effect. (Signature over Printed Name) (Date) -----------------------------------------------------------------FOR PAGCOR USE ONLY----------------------------------------------------------------- RECEIVED/VERIFIED BY CHECKED BY: PROCESSED BY: (Signature over Printed Name/Date) (Signature over Printed Name/Date) (Signature over Printed Name/Date)