OG Form 220 - Request for Transfer or Additional Accreditation to Another POGO Form

Page No. 1 of 1 REQUEST FOR TRANSFER OF AUTHORIZATION Form No. OGLD-220 TO ANOTHER LICENSEE FORM Revision No. 3 Effectivity July 13, 2023 Use this form to signify intent of Authorized Provider to apply for transfer of its existing accreditation to another Internet Gaming Licensee. Only requests with correct, complete information and documentary requirements will be processed. Applications with incorrect and/or incomplete information/requirements will be returned. PART A. COMPANY INFORMATION NAME OF APPLICANT: TYPE OF AUTHORIZATION: VALIDITY DATE OF AUTHORIZATION: PART B. AUTHORIZED REPRESENTATIVE INFORMATION (to be filled out by Authorized Representative) NAME: POSITION IN THE COMPANY: CONTACT NUMBER: EMAIL ADDRESS: PART C. TRANSFER OF AUTHORIZATION TO ANOTHER LICENSEE REQUEST/S CURRENT LICENSEE / ADDRESS NEW LICENSEE / ADDRESS (Note: Please use additional sheet/s if the space provided above is not sufficient) PART D. DOCUMENTARY REQUIREMENTS 1. Consent letter from current Licensee 2. Endorsement letter from new Licensee 3. Request for Transfer of Authorization to Another Licensee Form 4. Completely filled out Application Form 5. Notarized Service Agreement from new Licensee 6. Additional Requirements if there are material changes in the corporate structure: a. New Organizational Chart indicating names of the person/s occupying the position/s b. Board Resolution or Secretary’s Certificate appointing new Authorized Representative c. Updated Notarized Personal Disclosure Statements (PDS) of Authorized Representative and Key Officers d. Specimen Signature Card of new Authorized Representative 7. Letter of No Objection (if applicable) 8. Lease Agreement / Proof of Ownership of Operating Site (if applicable) 9. Proof of Payment 10. Other supporting documents that may be required as deemed necessary PART E. DECLARATION By signing below, I declare that I am duly authorized to submit the application on behalf of the corporation; that the information contained herein and which accompanies this application is true and accurate to the best of my knowledge and understanding; and the company agree to abide by the provisions of the Internet Gaming Licensing Regulations which will be the law governing the applicant’s relationship with PAGCOR. _______________________________________ SIGNATURE OVER PRINTED NAME