OG Form 1535 - Declaration of Security Compliance Officer Form

Page No. 1 of 1 DECLARATION OF SECURITY Form No. OGLD-1535 COMPLIANCE OFFICER FORM Revision No. 3 Effectivity April 23, 2025 PART A: GENERAL INSTRUCTIONS 1. Use this form to designate/update the Security Compliance Officer of the company declared with PAGCOR. 2. Write your answers in block letters. If the information required is not applicable, write “NA” 3. Print your application form and all documentary requirements on an A4-size paper. 4. Original documents must be submitted to the OGLD Office. Applications with incomplete information / requirements will not be accepted. Note: for any inquiries regarding your application, you may contact OGLD through : 8522 0299 local 1178 PART B : REQUIRED ATTACHMENTS / SUPPORTING DOCUMENTS This notification form must be accompanied by the following supporting documents: 1. Personal Disclosure Statement (PDS) of New Authorized Representative PART C. NOTIFICATION DETAILS DATE: NAME OF COMPANY: TYPE OF LICENSE / ACCREDITATION: COMPANY EMAIL ADDRESS: COMPANY CONTACT NUMBER: NEWLY-APPOINTED SECURITY COMPLIANCE OFFICER: NAME OF NEW REPRESENTATIVE: CONTACT NUMBER/S: EMAIL ADDRESS: SPECIMEN SIGNATURES: 1. ________________________ 2. ________________________ 3. ________________________ PART D. NAME OF DECLARANT (to be filled out by Corporate Secretary) PRINTED NAME: POSITION TITLE: CONTACT NUMBER: EMAIL ADDRESS: ________________________________________ SIGNATURE OVER PRINTED NAME