Supplier's Enrollment Form

Page No. Page 1 of 2

Form No. GLDD-1009 SUPPLIER'S ENROLLMENT FORM Revision No. 4 PAGCI Effectivity July 12, 2023

STRICTLY CONFIDENTIAL

1 Name of Supplier:

2. Other Business Name the Supplier has operated under (if any)

3.Head Office I Business Address:

4.Local Business Address (if any)

5.Tel. No. 6 Fax No.

7 Email Address. 8. Company Website

0 Proprietorship Date Issued: Sole Corporation Business Structure: Check the appropriate box as it applies to your business SEC Reg No.: Date Issued: DTI Reg No.: Partnership Others Date Issued: SEC Reg No. (Please specify)

10. Name:

1 1. Position or Title in the Company (e.g., board of director/secretary etc)

12. Tel.No. 13.FaxNo.

14.Mobile No. 15.Email Address

Authorized representative signature:

Page No. Page 2 of 2

Form No. GLDD-1009 SUPPLIER'S ENROLLMENT FORM Revision No 4 PAGCO

Effectivity July 12, 2023

STRICTLY CONFIDENTIAL

16.PRODUCT/S

Slot Machine Spare parts/ Accessories Gaming Paraphernalia Slot Machine Playing Cards Gaming Table Layout Surveillance Equipment Gaming Table Game Conversion kits Casino Management System for Tables, Slots or E-bingo, Bingo Bingo Paraphernalia Chips/Plaques Signages Bingo Flashboard

17. Provide the name and contact information of the company you are supplying for (if applicable) Electronic Bingo Machine/Terminals Bingo machine or console Electronic Table Game Terminals Others (Please Specify) Bingo Tickets Bingo Balls

18. Provide the name and contact information of the company you are supplying to (if applicable)

details below license, permit or other qualification that has been suspended, revoked, withdrawn. Provide the 19. List all other gaming jurisdictions with which you have applied for a certificate, registration

Jurisdiction Name of Address Qualification Type of Date of Issuance and Expiration

20. List all other gaming jurisdictions with which you have applied for a certificate, registration, license permit or other qualifications that has been refused, suspended, revoked, withdrawn. Provide the details below Jurisdiction Name of Address Qualification Type of Reason of Action

Authorized representative signature