GS Form No.

38-B
(v.1) 06.23.2017

Philippine Amusement and Gaming Corporation

Gaming Licensing and Development Department
PAGCOR House, 1330 Roxas Boulevard, Ermita, Manila

REQUEST FOR AMENDMENT TO GAMING LICENSE FORM

(Operator's Conversion from Sole Proprietorship/Partnership to Corporation)

GENERAL INSTRUCTIONS
1. Use this form if the Operator intends to convert from Sole Proprietorship/Partnership to a Corporation
which requires for an amendment to the existing Gaming License of good standing.
2. The Operator must comply with the requirements for conversion as prescribed in Section 1-(b) under
Regulation 2 and Section 5 under Regulation 6 of the Gaming Site Regulatory Manual (GSRM).
3. Type or print the needed information on the spaces provided. The Operator must provide all required
information. Incomplete requirements will cause the non-processing of this request.
4. Please accomplish and submit this form together with the prescribed documentary requirements, to:
Gaming Licensing and Development Department (GLDD)
Room 314, 3rd Floor PAGCOR House
1330 Roxas Boulevard, Ermita, Manila
Attention: Merlie V. Rubin
Acting Senior Regulatory Officer
or email to
[email protected]
[email protected]
5. Cut-off for submission of applicants shall be 4:00 P.M

1. Name of Operator:
(If Operator is a partnership, please provide full registered name.)

Please check type of current gaming activity at gaming site

Bingo Games Electronic Bingo Traditional Bingo

Electronic Games InstaWin

2. Validity of Current Gaming License (GL): From: To:

3. Existing Gaming Site Location:

4. Registered Name as Corporation:

A. This request is accompanied by the following LGU document (if any) and Applicant-Corporation documents:
(1) Letter of No Objection (LONO) document from the concerned Local Government Unit (LGU)

(i.e. Resolution from the City/Municipal Council) Date issued:

(If the current Gaming License was issued based on duly received application with the City/Municipal Council
and letter of consent from the Mayor as previously allowed prior to the amendment of the GSRM)
Note: PAGCOR reserves the right to conduct extra due diligence on submitted LGU documents.

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 GS Form No. 38-B
(v.1) 06.23.2017

DATE RECEIVED
(2) Applicant-Corporation Documents by GLDD
a. Company profile
b. SEC Registration
c. Latest General Information Sheet (GIS) duly stamped received by SEC
d. Articles of Incorporation, By-Laws duly stamped received by SEC:
Articles of Incorporation must show that gaming is one of its primary purpose of business;
if secondary purpose, a copy of the Board's Ratificatory Vote on the same should be submitted;
Foreign ownership, if any, must comply with the Regular Foreign Negative List B of the Foreign
Investment Acts of 1991 B69 (R.A. No. 7042, as amended by R.A. No. 8179)
If a stockholder is also a corporation, a copy of the SEC Registration, Articles of Incorporation
and latest GIS of said corporation should likewise be submitted
Authorized Capital Stock of at least FIVE MILLION PESOS (PhP 5,000,000.00), with paid-up capital
of at least THREE MILLION PESOS (PhP3,000,000.00)
e. Original bank certification [must have a minimum of THREE MILLION PESOS (PhP 3,000,000.00)]
per game offering under the Applicant company's name
specific requirements)
f. Copy of ITR of the company (duly filed with the BIR) for the previous year for existing incorporated
corporations or copy of current balance sheet of the newly incorporated corporation
g. Written disclosure of the description of any of the following events that occurred during the past
five (5) years up to the latest date that are material to an evaluation of the ability or integrity of any
director of shareholder of the Applicant:
1. Any bankruptcy petition filed by or against any business of which such person was a director
or shareholder either at the time of the bankruptcy or within two years prior to that time;
2. Any conviction by final judgment, including the nature of the offense, in a criminal proceeding,
domestic or foreign, or being subject to a pending criminal proceeding, domestic or foreign,
excluding traffic violations and other minor offenses;
3. Being subject to any order, judgment, or decree, not subsequently reversed, suspended or
vacated, of any court of competent jurisdiction, domestic or foreign, permanently or
temporarily enjoining, barring, suspending, or otherwise limiting his involvement in any type
of business of gaming activities; and
4. Being found by a domestic or foreign court of competent jurisdiction (in a civil action), PAGCOR,
or a domestic regulatory organization to have violated gaming law or regulation, and the judgment
has not been reversed, suspended, or vacated.
h. Written disclosure of relatives in PAGCOR or other government agencies up to the 4 th civil degree of
consanguinity or affinity
i. Sworn undertaking that Applicant will abide by existing labor laws, including regularizing all
contractual employees working for more than six (6) months and the payment of minimum wages
and the benefits mandated under labor laws
j. Sworn certification that the gaming site has complied/will comply with the required Performance
Cash Deposit and Initial Betting Fund, as applicable.

(3) For Each Member of the Board of Directors:

Duly accomplished and notarized Personal Disclosure Statement (PDS) form - to be sent together with
enclosures in a sealed brown envelope marked "CONFIDENTIAL - PDS" addressed to:

Senior Manager, RGU

Gaming Licensing and Development Department
3rd Floor PAGCOR House
1330 Roxas Boulevard, Ermita, Manila

Enclosures with the PDS form are the following:

1. For Filipino citizens and foreign residents; copy of ITR (duly filed with the BIR) for the previous year; or
2. For non-resident foreigners: copy of valid passport

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 GS Form No. 38-B
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DECLARATION
By signing below, I/We declare that:

1 The information contained in this request including all documents submitted relative to this are valid, true
and correct;
2 I/We declare and certify that the location of the gaming site is the same as the existing gaming site.
3 I/We declare and certify that the site location is still compliant with the distance restriction guidelines to
schools, places of worship, cockpits, horse-racing outlets, public markets, informal settlers, resettlement
areas, and other gaming establishments as prescribed in Section 2 under Regulation 3 of the GSRM.
4 I/We understand that validity of the amended Gaming License (GL) shall be the unexpired term of the
original GL.
5 I/We have executed this statement with the knowledge that misrepresentation or failure to reveal
information requested may be deemed sufficient cause for revocation of the GL of the gaming site if
amendment to GL has been approved by the time such misrepresentation or act of omission is discovered.
6 I/We are certifying that the proposed gaming site is compliant with the LGU's requirements and
regulations on the establishment; and that I/we will not hold PAGCOR liable for expenses/"business losses"
brought about by closure orders and/or penalties incurred should site be found non-compliant with LGU
regulations.
7 I/We declare that I/we shall undertake to secure an amended Business Permit to correspond with the new
name as the Operator of the gaming site, should my/our request be approved.

Name: _________________________________________ Signature: _____________________________

AUTHORIZED REPRESENTATIVE
Date:

EVALUATION
(to be accomplished by GLDD)

A. Conversion from Sole Proprietorship/Partnership to Corporation is acceptable in terms of the site

location and compliance with the submission of Operator-Corporation documentary requirements.
Acceptability of this conversion is not a guarantee of the approval of this request. The grant of
amended Gaming License of a gaming site is subject to PAGCOR Board approval.

_______________________________________
GLDD EVALUATOR Date
B. Request is returned due to insufficient requirements/information:
Acknowledged by:

______________________________________ _________________________________________
GLDD EVALUATOR AUTHORIZED REPRESENTATIVE
Date: Date:

C. Conversion from Sole Proprietorship/Partnership to Corporation is unacceptable due to:

_________ License is not of good standing
_________ Location of the gaming site is not the same as the existing gaming site
_________ Site location is currently not compliant with the distance restriction guidelines
Remarks:
Acknowledged by:
___________________________ _________________________________________
GLDD EVALUATOR APPLICANT or AUTHORIZED REPRESENTATIVE
Date: ____________________ Date: ____________________