1.23 VOLUNTARY CLOSURE/ NON-RENEWAL OF GAMING LICENSE

VOLUNTARY CLOSURE / NON RENEWAL Page No. Page 1 of 1 OF GAMING LICENSE NOTIFICATION Form No. EGLD - 435 FORM Rev. No. 5 Remote Games Effectivity July 17, 2024 EG Form No. 30 EGLD Reference No.: _________________ Use this form to notify PAGCOR at least fifteen (15) business days prior to the intended voluntary closure of gaming venue or non-renewal of Gaming License. Please accomplish this form by providing correct and complete information. Cut-off for submission of notifications shall be 4:00 P.M. SSECTION A: NOTIFICATION DETAILS (TO BE FILLED UP BY THE OPERATOR) ) 1. Name of Operator: __________________________________________________________ (as reflected in the gaming license) 2. Gaming Venue: __________________________________________________________ __________________________________________________________ (as reflected in the gaming license) 3. Gaming License Reg No: _________________ Gaming License Validity: __________________ 4. Game Offering: __________________________________________________________ Service Provider/s: __________________________________________________________ Brand/s: __________________________________________________________ 5. Reason for voluntary closure or non-renewal of Gaming License of gaming venue: __________________________________________________________________________________ 6. This notification form is accompanied by the following documents:  Copy of latest GIS duly received by SEC; and  Board resolution or Secretary’s Certificate stating that the corporation is pre-terminating the Gaming License issued for its above-named gaming venue. By: Printed Name: _______________________________________ Signature: _________________ (Operator/Authorized Signatory) Position Title: _______________________________________ Date: _________________ SECTION B: SUBMISSION INSTRUCTIONS Once Section A is completed, please submit/mail/e-mail this form to EGLD together with supporting documents to the address/e-mail address indicated below: Electronic Gaming Licensing Department Philippine Amusement and Gaming Corporation 10th Floor MET LIVE BUILDING Central Business Park 1-A Macapagal Boulevard cor. EDSA Extension, Pasay City 1300 Tel Nos.: (+632) 8522-0299 / 8521-1542 loc. 1561 E-mail address: [email protected] SECTION C: ACKNOWLEDGEMENT OF NOTIFICATION (TO BE FILLED UP BY EGLD) ) RECEIVED for PROCESSING with REFERENCE NO. : ___________________________________ Printed Name: _______________________________________ Signature: _________________ Position Title: _______________________________________ Date: _________________