OG Form 1057 - Revised Request for Amendment to Gaming License Form

Page No. 1 of 1 REQUEST FOR AMENDMENT OF Form No. OGLD-1057 GAMING LICENSE FORM Revision No. 5 Effectivity Aug. 9, 2023 Use this form to signify intent to apply for an amendment to the gaming license previously registered with PAGCOR such as (1) Change of Company Name and (2) Correction of Operating Address. Only requests with correct, complete information and documentary requirements will be processed. Applications with incorrect and/or incomplete information/requirements will be returned. ALL AMENDMENTS ARE SUBJECT TO POST-AUDIT/ INSPECTION TYPE OF AMENDMENT: Change of Company Name Correction of Operating Address PART A. COMPANY INFORMATION NAME OF APPLICANT: TYPE OF LICENSE / AUTHORIZATION: REASON/S FOR AMENDMENT: PART B. AMENDMENT REQUEST/S: AMENDMENT COMPANY DETAILS FROM TO (Note: Please use additional sheet/s if the space provided above is not sufficient) Required Attachments: Old Certificate LONO & Lease Agreement (Only applicable for Correction of Operating Address) Amended SEC Registration (Only applicable for Change of Company Name) 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)