Cancellation of License / Accreditation Form, ROASD-566, Revision 0

Page No. 1 of 1 CANCELLATION OF LICENSE / Form No. ROASD-566 ACCREDITATION FORM Revision No. Effectivity 0 Jun. 29, 2026 PART A: GENERAL INSTRUCTIONS 1. Use this form to signify the Company’s intent to cancel its existing license / accreditation registered 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 PAGCOR - 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 indicating the reason/s for the cancellation and the intended effectivity date Board Resolution / Director’s Certificate signifying the Company’s decision for voluntary cancellation of its license/accreditation Latest General Information Sheet with beneficial owner page Notarized declaration that the Remote Play Licensee/SCBPO/DSP holds PAGCOR free and not liable from any claim and/or liability from any tax obligation which may be imposed by any taxing authority on the fees or earnings due to cancellation of its license/accreditation and that they will be solely responsible for any action or suit brought about by any third party in relation to their license/accreditation. Notarized Undertaking to conduct post-operational activities within 30 days from the approval of the cancellation Proof of full settlement of arrears and/or penalty/ies (if applicable) Surrender of the previously issued License / Certificate of Accreditation ALL REQUEST FOR CANCELLATION OF LICENSE / ACCREDITATION MUST BE SUBMITTED TO PAGCOR-ROASD AT LEAST 30 DAYS PRIOR TO THE EFFECTIVITY DATE OF CANCELLATION PART C. NOTIFICATION DETAILS DATE: NAME OF COMPANY: TYPE OF LICENSE / ACCREDITATION: REASON FOR CANCELLATION: INTENDED DATE OF EFFECTIVITY: 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. AUTHORIZED REPRESENTATIVE PRINTED NAME: POSITION TITLE: CONTACT NUMBER: EMAIL ADDRESS: ________________________________________ SIGNATURE OVER PRINTED NAME