Additional Site / Address Notification Form, ROASD-1056, Revision-0

Page No. 1 of 1 Form No. ROASD-1056 ADDITIONAL SITE FORM Revision No. 0 Effectivity Jun. 29, 2026 PART A: GENERAL INSTRUCTIONS 1. Use this form to signify the Company’s intent to apply for operating site/s in addition to its existing registered operating address/es with PAGCOR. 2. Write your answers in block letters. If the information required is not applicable, write “NA” 3. Print your application form and all documentary requirements on an A4-size paper. 4. Original documents must be submitted to the ROASD Office. Applications with incomplete information / requirements will not be accepted. Note: For any inquiries regarding your application, you may contact ROASD through : 8522 0299 local 1188 / 1189 PART B : REQUIRED ATTACHMENTS / SUPPORTING DOCUMENTS This notification form must be accompanied by the following supporting documents: Letter request for the additional operating site/s Lease Agreement covering the additional operating site/s Valid Mayor’s Permit / Business Permit Certified True Copy of BIR Registration of the additional operating site/s Certified True Copy of Letter of No Objection (for RPP/RPSM applicant) ALL REQUESTS FOR ADDITIONAL OPERATING SITE/S SHALL BE SUBJECT TO INSPECTION PART C. NOTIFICATION DETAILS DATE: NAME OF COMPANY: TYPE OF LICENSE / ACCREDITATION: EXISTING OPERATING ADDRESS/ES: FLOOR AREA 1. 2. 3. 4. 5. (Note: Please use additional sheet/s if the space provided above is not sufficient) ADDITIONAL OPERATING ADDRESS/ES: FLOOR AREA 1. 2. 3. 4. 5. (Note: Please use additional sheet/s if the space provided above is not sufficient) PART D. NAME OF AUTHORIZED REPRESENTATIVE PRINTED NAME: POSITION TITLE: CONTACT NUMBER: EMAIL ADDRESS: ________________________________________ SIGNATURE OVER PRINTED NAME