1.4 REQUEST FOR RENEWAL OF GAMING LICENSE FORM

Page No. Page 1 of 1 REQUEST FOR Form No. EGLD - 418 RENEWAL OF GAMING LICENSE FORM Rev. No. 6 Remote Games Effectivity July 17, 2024 EG Form No. 3 EGLD Reference No.: __________________ Use this form if Operator intends to renew its Gaming License (GL). Please submit this form not later than thirty (30) days prior to expiration of GL. Type or print the needed information on the spaces provided. Incomplete requirements and/or non- compliance with the gaming venue requirements will cause the non-renewal of the Gaming License subject to the guidelines as prescribed in the Regulatory Framework for the Issuance of Gaming License for the Establishment of Gaming Venues. SECTION A: REQUEST DETAILS (TO BE FILLED UP BY THE OPERATOR) Name of Operator: _________________________________________________________________ (As reflected in the gaming license) Gaming Venue: _________________________________________________________________ (As reflected in the gaming license) Gaming License No.: _______________________ Current GL Validity: ________________________ Game Offering: _______________________ Brand/s: _________________________________ SECTION B: DECLARATION (TO BE FILLED UP BY THE OPERATOR) By signing below, we declare that: 1. We signify our intention to renew the Gaming License indicated above and this is accompanied by Payment Processing Request Form (EG Form No. 2) and copy of O.R. of renewal fee. 2. We understand that application for renewal filed later than 30 days prior to the expiration of our License is imposable of a penalty amounting to Php30,000.00. 3. We have no unpaid penalty and/or extension fees. 4. The gaming venue as indicated above is compliant with the prescribed minimum number of operational terminals or seating capacity, as the case may be. 5. We are compliant with the submission of Business Permit during the annual submission of documents. 6. The Performance Cash Deposit (PCD) posted to PAGCOR for the above gaming venue operations is compliant with the existing rates. 7. We shall file the request for an extension of our renewal application before the expiration date of our License, or approved extended period, if any, with corresponding extension fee, as deemed necessary. 8. We understand that non-filing of Request for Extension of Application (EG Form No. 4) and non- payment of Extension Fee shall result to expiration of the License and same can no longer be the subject of renewal. 9. We understand, in case of non-renewal/revocation of the License, any unpaid Extension Fee and/or Renewal Fee, as applicable, shall be deducted from the refundable PCD amount. Printed Name:_____________________________________ Signature: ___________________ (Authorized Representative) Position Title:______________________________________ Date: ____________________ SECTION C: SUBMISSION INSTRUCTIONS Once Section A is completed, please submit/mail/email this form to EGLD together with supporting documents to the address/e-mail address indicated below: Electronic Gaming Licensing Department Philippine Amusement and Gaming Corporation 10th Floor MET LIVE BUILDING Central Business Park 1-A Macapagal Boulevard cor. EDSA Extension, Pasay City 1300 Tel Nos.: (+632) 8522-0299 / 8521-1542 loc. 1561 Email address: [email protected] SECTION D: ACKNOWLEDGEMENT OF NOTIFICATION (TO BE FILLED UP BY EGLD) RECEIVED for PROCESSING with REFERENCE NO. : ___________________________________ Printed Name: ______________________________________ Signature: __________________ Position Title: ______________________________________ Date: __________________