Certificate / Permit Reprinting Form, ROASD-485, Revision-0

Page No. 1 of 1 CERTIFICATE / PERMIT Form No. ROASD-485 Revision No. 0 REPRINTING FORM Effectivity August 4, 2026  Please use this form to request for Reprinting of PAGCOR-issued Certificates and Permits.  Only requests with correct and complete information as well as proper attachments will be processed.  Kindly submit one (1) form per request. AN AFFIDAVIT OF LOSS (IF APPLICABLE) SHOULD BE PRESENTED IN ORDER TO PROCESS THIS APPLICATION PART A. COMPANY INFORMATION / REQUEST NAME OF APPLICANT: TYPE OF ACCREDITATION: ADDRESS: ACCREDITATION NO.: REASON FOR THE REQUEST FOR REPRINTING: PART B. AUTHORIZED REPRESENTATIVE INFORMATION NAME: POSITION IN THE COMPANY: CONTACT NUMBER: EMAIL ADDRESS: ________________________________________ SIGNATURE OVER PRINTED NAME ______________________ DATE