OG Form 368 - Remote Play Slot Machine Request For Break Seal and Seal Back Form

PAGE NO. Page 1 of 3 REMOTE PLAY SLOT MACHINE REQUEST FORM NO. OGLD-368 FOR BREAK SEAL AND SEAL BACK FORM REVISION NO. 0 EFFECTIVITY Oct. 18, 2023 Use this form to notify PAGCOR regarding for Break Seal and Seal Back of Slot Machines. Please accomplish this form by providing correct and complete information. The Licensee shall submit this form to OGLD at least three (3) business days prior to intended date of implementation. PLEASE NOTE THAT PAGCOR RESERVES THE RIGHT TO CONDUCT POST-AUDIT OF THE BREAK SEAL AND SEAL BACK ACTIVITY. Licensee: ______________________________________________________________________________ Location: ______________________________________________________ Date: ___________________ Purpose : ______________________________________________________________________________ (Please specify the reason e.g. for movement, change in parameter settings, conversion, cessation, RAM corrupted etc.) Date of Activity: ________________________ Number of machines: _________________ Time duration: __________________________ Effectivity Date: _____________________ SECTION A: BREAK SEAL AND SEAL BACK OF REMOTE PLAY SLOT MACHINE (TO BE PROVIDED BY LICENSEE) Gaming Equipment: Action taken: SM For RAM Clear Controller No RAM Clear Server For Repair Others: For Replacement a. The conduct of break seal and seal back activity shall be coordinated w ith the Compliance Monitoring and Enforcement Department and the PAGCOR Monitoring Team. Name of Requestor : Signature : Position Title : Date : SECTION B: SUBMISSION INSTRUCTIONS Once Section A is completed, please submit this form to OGLD along with the necessary attachments. Hard copies may be submitted directly to the OGLD office or scanned copies of the documents may be emailed using the e-mail address of the concerned Licensee indicated below: Offshore Gaming Licensing Department Philippine Amusement and Gaming Corporation 6th Floor, PAGCOR Executive Office, New Coast Hotel Manila, 1588 M.H. Del Pilar corner Pedro Gil Street, Malate, Manila 1004 Tel. No. (02)8242-01-21 E-mail address: [email protected] If submission of this notification form is done thru e-mail, the Licensee should ensure that the email has been duly received and acknowledged by OGLD. The Licensee shall be notified by OGLD also thru e-mail confirming receipt of this form. If no-e-mail confirmation is received from OGLD, the Licensee should submit the hard copy directly to OGLD. SECTION C : ACTION TAKEN (TO BE FILLED UP BY OGLD) a. ACKNOWLEDGEMENT OF NOTIFICATION RECEIVED with reference no. ______________________ By: Printed Name: ___________________________ Signature: ____________________________ Position Title: ___________________________ Date and Time: ________________________ b. FOR APPROVAL Approved by: Printed Name: ___________________________ Signature: _____________________________ Position Title: ___________________________ Date and Time: _________________________

PAGE NO. Page 2 of 3 REMOTE PLAY SLOT MACHINE REQUEST FORM NO. OGLD-368 FOR BREAK SEAL AND SEAL BACK FORM REVISION NO. 0 EFFECTIVITY Oct. 18, 2023 INVENTORY LIST OF REMOTE PLAY SLOT MACHINES FOR BREAK SEAL AND SEAL BACK No. SM No. PAGCOR Tag No. Serial No. Link Game Name Remarks 1 2 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 17 18 19 20 21 22 23 24 25 26 27 28 29 30

PAGE NO. Page 3 of 3 REMOTE PLAY SLOT MACHINE REQUEST FORM NO. OGLD-368 FOR BREAK SEAL AND SEAL BACK FORM REVISION NO. 0 EFFECTIVITY Oct. 18, 2023