Shipment / Ship-out Processing Fee Payment Slip Form

GLDD Payment Slip Form

Page No. Page 1 of 1

PAGCOR SHIPMENT/SHIP-OUT PROCESSING FEE PAYMENT SLIP FORM Form No. Revision No. GLDD - 1202 3

Effectivity June 12, 2023

shipment/ship-out request. One Shipment/Ship-out Processing Fee Payment Slip Form per approved Shipment/Ship-out Clearance Use this form to transmit payment/s for shipment/ship-out processing fee due to PAGCOR relative to the processing of shipment/ship-out of gaming equipment and gaming paraphernalia. Only Shipment/Ship-out Clearance Request Approval Form with correct and complete information ana supporting documents will be processed. Failure to provide correct and complete information could result in non-processing of the said Request Approval Form.

SECTION A:PAYMENTINFORMATIONIDETAILS(TO BE FILLED UP BY LICENSEE/SUPPLIER)

Licensee Supplier

Name of Licensee/Supplier:

Address:

T.I.N. : (to be filled-up by new Licensee/Supplier only)

Pavment Mode: Cash in the amount of

Check/s with details as follows:

Check No. Amount* Date* Name of Bank & Branch*

Bank Deposit

Date of Deposit Amount* Name of Landbank Branch Branch Code

3) in the event that a check is returned by the bank due to insufficient funds or any other reason, the Licensee/Supplier shall settle the 2) It is understood that Check payments shall be subject to three (3) days clearing period before an Official Receipt is issued by FTD 1) * Please fill up also for deposits made to PAGCOR OPEX Account arrears in cash or by issuing a Manager's Check For Bank Deposit please attach a copy of bank validated deposit slip.

SECTION B: PAYMENT DETAILS (TO BE FILLED UP BY PAGCOR GLDD)

Ship-Out Clearance Shipment Clearance GLDD Reference no. Commercial Invoice No.

SECTION C: SUBMISSION INSTRUCTIONS Once Section A is completed, please submit this form together with the supporting payment documents as indicated below:

For cash/check payments, please proceed to For deposits to PAGCOR Opex Account, here are the bank details: Gaming Licensing and Development Department Philippine Amusement and Gaming Corporation 12th Floor iMET BPO Tower CBP-1A Metropolitan Park Roxas BIvd., Pasay City Issuance of O.R. by FTD shall be a pre-requisite for processing of shipment/ship-out clearance. Account Name: Account no: Landbank Branch: Note : Please furnish the GLDD with a copy of this form duly received by FTD and a copy of the corresponding Official " Receipt (O.R.). LBP Plaza, Malate, Manila PAGCOR OPEX Fund CIA No. 3402-1036-70

PAGCOR shall not be held liable for any delay in the processing caused by incomplete submissions