PAGCOR Personal Disclosure Statement Form

PERSONAL DISCLOSURE STATEMENT (PDS)
(Year ______)
INSTRUCTIONS
1) Write your answers in block letters. If a question does not
apply to you, write NA.
2) Place a cross [ X ] in the box if one is provided.
3) Affix a 2x2 colored photograph taken within the past 6
months
4) Send the accomplished and notarized PDS and
enclosures in a sealed brown envelope marked
CONFIDENTIAL PDS addressed to:
Affix 2 x 2
colored photo here
Senior Manager, Remote Gaming Unit

Gaming Licensing and Development Department
3rd Floor PAGCOR House
1330 Roxas Boulevard, Ermita, Manila 1000
Part 1
PERSONAL INFORMATION
NAME
(Last Name)
(First Name)
(Middle Name)
Alias/Other Name
Sex
Male
Date of Birth
(Day of Month)
Female
(Month in words)
(Year in full)
Nationality
Tax Identification No.
(TIN)
CONTACT INFORMATION
Address
Telephone No.
Mobile No.
Email Address
Initials: _________________________
(v.4) 11.25.2015
Date: _________________ (Day / Month / Year)

Page 1 of 4
RELATIVES IN PAGCOR, if any

Name
Name
Part 2
ALL AFFILIATIONS WITH PAGCOR LICENSEES
Name/s of registered
company/ies or
partnership/s
Part 3
INTEGRITY AND FINANCIAL SOUNDNESS
The questions below are for any jurisdiction. If you answer YES to any question, please
provide details in a separate sheet. Indicate offenses and/or circumstances that transpired
within and outside the Philippines.
2.1
Have you ever been convicted of an offense?
Yes
No
2.2
Have you been charged with an offense and awaiting hearing; or

otherwise subject to a pending prosecution?
Yes
No
To your knowledge, are you under investigation by

The police, customs or any law enforcement agency
Yes
No
2.3
Any other government agency
Yes
No
Any professional body, trade association or industry

regulator
Yes
No
2.4
Have you ever been censured, disciplined or made subject of an

order by any professional body, trade association or industry
regulator?
Yes
No
2.5
Have you ever been:

Disqualified from acting as a director of a company
Prohibited or prevented from acting in the management or
conduct of the affairs of any company, partnership or
association
Dismissed, discharged or asked to resign from any
employment
Yes
No
2.6
Have you ever held a Directorship or other senior appointment with

any company, partnership or business entity which has been
placed during your term into
Liquidation
Receivership
Insolvency
Any kind of regulatory administration or monitoring
Yes
No
2.7
Have you in your personal capacity been declared insolvent by a

competent regulatory body?
Yes
No
Initials: _________________________
(v.4) 11.25.2015

Page 2 of 4
Part 4
PROFESSIONAL HISTORY
Please use separate sheet as needed.

Year
From
To
Part 5
Nature of
Business
Company
Position Title
ENCLOSURES
5.1
For Filipino citizens and foreign residents: copy of ITR (duly filed with the BIR) for the
previous year
5.2
For non-resident foreigners: copy of valid passport
Part 6
DECLARATION AND CONFIDENTIALITY
I certify that the information provided in this PDS is true, complete and correct as to my
personal knowledge and/or on the basis of authentic documents in my possession at the
time of execution of this PDS.
I undertake to provide any further information that PAGCOR may reasonably require about
this PDS.
I am aware that PAGCOR recognizes my eligibility for membership in the Board of Directors
of a PAGCOR-licensed entity on the sole basis of the information provided in this PDS.
I understand that the information in this PDS was collected for the sole purpose of
demonstrating my eligibility for membership in the Board of Directors of a PAGCOR-licensed
entity. As such, the information will be treated with confidentiality and privacy and may not
be disclosed to third parties without my prior written consent.
For directors of listed licensees:
I confirm that I have all the qualifications and none of the disqualifications for a director
under relevant laws, circulars and regulations of the Securities and Exchange Commission
and the Philippine Stock Exchange, as well as the Articles of Incorporation and By-Laws of
________________________________________________________________________.
(State the name of Licensee)
Initials: _________________________
(v.4) 11.25.2015

Page 3 of 4
IN WITNESS WHEREOF, I hereby affix my signature this ________of ______________ at

Manila, Philippines.
_____________________________
Affiant
SUBSCRIBED AND SWORN to before me this ________ day of ___________ at

_____________ affiant exhibited to me his Community Tax Certificate/Passport No.
_____________ issued on ___________ at _______________.
Doc. No. ______;

Page No. ______;
Book No. ______;
Series of 20___
Initials: _________________________
(v.4) 11.25.2015

Page 4 of 4

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PERSONAL DISCLOSURE STATEMENT (PDS)

Senior Manager, Remote Gaming Unit

Date: _________________ (Day / Month / Year)

RELATIVES IN PAGCOR, if any

ALL AFFILIATIONS WITH PAGCOR LICENSEES

INTEGRITY AND FINANCIAL SOUNDNESS

Have you ever been convicted of an offense?

Have you been charged with an offense and awaiting hearing; or

To your knowledge, are you under investigation by

Any other government agency

Any professional body, trade association or industry

Have you ever been censured, disciplined or made subject of an

Have you ever been:

Have you ever held a Directorship or other senior appointment with

Have you in your personal capacity been declared insolvent by a

Date: _________________ (Day / Month / Year)

Please use separate sheet as needed.

For non-resident foreigners: copy of valid passport

DECLARATION AND CONFIDENTIALITY

Date: _________________ (Day / Month / Year)

IN WITNESS WHEREOF, I hereby affix my signature this ________of ______________ at

SUBSCRIBED AND SWORN to before me this ________ day of ___________ at

Doc. No. ______;

Date: _________________ (Day / Month / Year)

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IN WITNESS WHEREOF, I hereby affix my signature this of ______ at

SUBSCRIBED AND SWORN to before me this day of ___ at