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Confidential: Interactive Gaming Licence Application Form

This document is an application form for an interactive gaming license from the Cagayan Economic Zone & Free Port in the Philippines. The form requests information such as the applicant's name, company number, addresses, contact details, and a declaration that the applicant is authorized to submit the application. It notes that the application must be accompanied by probity forms, the prescribed fee, a business plan, and a signed code of practice. The applicant must sign and date the form, which is submitted to the Regulator of Interactive Gaming.

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Ace Christian Ocampo
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54 views2 pages

Confidential: Interactive Gaming Licence Application Form

This document is an application form for an interactive gaming license from the Cagayan Economic Zone & Free Port in the Philippines. The form requests information such as the applicant's name, company number, addresses, contact details, and a declaration that the applicant is authorized to submit the application. It notes that the application must be accompanied by probity forms, the prescribed fee, a business plan, and a signed code of practice. The applicant must sign and date the form, which is submitted to the Regulator of Interactive Gaming.

Uploaded by

Ace Christian Ocampo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

CONFIDENTIAL

Cagayan Economic Zone & Free Port


Republic of the Philippines

INTERACTIVE GAMING LICENCE


APPLICATION FORM
Pursuant to the
Interactive Gaming Act 2003
Form Number CEZA-003

Applicants Name: ___________________________________________________


Company Number: ___________________________________________________
Registered Office: ___________________________________________________
___________________________________________________
Postal Address:

___________________________________________________
___________________________________________________

Address of Proposed Premises: _________________________________________


___________________________________________________
Telephone Number:___________________________
Facsimile Number: ___________________________
Email Address:

___________________________

Contact Name:

___________________________

License Application Form

1 of 2

Version: 1.0

DECLARATION (if applicable):


In the case of a Company/Body Corporate, I/we certify that I/we am/are duly
authorised to make the application on behalf of the Company/Body Corporate.
Executed under the common seal of
______________________________________________________
(If applicable)

(Name of Company/Body Corporate)

Signature:

_____________________________________

Name:

_____________________________________

(Seal)

(Please Print)

This application must be accompanied by:


a completed Company Probity Form (if applicable) in respect of the
applicant;
a completed Personal Probity Form at least in respect of each company
director, the company secretary and the chief executive officer; and
the prescribed fee; and
A copy of your Business Plan; and
A signed copy of the Industry Code of Practice.
Applicant Signature:

_____________

Date:

_____ / _____ / _____

In the presence of:

____________________
(Signature of Witness)
Name of Witness: ___________________
Address of Witness:___________________
___________________
___________________

Note:
If an applicant attempts to obtain an Interactive Gaming Licence by a materially false or misleading representation
or in some other improper way, this will impact when assessing the suitability of the applicant. Further, section 4
of the Interactive Gaming Act (2003) provides that if an Interactive Gaming Licence is obtained by a materially
false or misleading representation, or in some other improper way, this is a ground for suspending or cancelling
the licence.
The completed application form, fee and attachments should be forwarded to:
The Regulator of Interactive Gaming
Cagayan Economic Zone & Free Port
th
26 Floor, West Tower
Philippine Stock Exchange Centre
Exchange Road, Ortigas Centre
Pasig City 1605, Philippines

License Application Form

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Version: 1.0

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