GS Form. No.

38A
(v.1.2) 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

(Change in Location of Gaming Site)

GENERAL INSTRUCTIONS
1. Use this form if the Operator intends to request for an amendment to the existing Gaming License of
good standing, resulting from change of a gaming site location.
2. The proposed site must satisfy the qualifications prescribed in Section 3 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
gldd.rgulicensing@pagcor.ph
gldd_ebingo@pagcor.ph
5. Cut-off for submission of applications shall be 4:00 P.M.

1. Name of Operator:
(please provide full registered name)
Please check type of current gaming activity at gaming site
Bingo Games Electronic Bingo Traditional Bingo

Electronic Games InstaWin

Other Games MSW Sports Betting Poker Club

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

3. Current Gaming Site Location:

4. Proposed Gaming Site Address:

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 GS Form. No. 38A
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INITIAL SITE REQUIREMENTS SUBMITTED

1 Location Map of proposed site showing distances to schools, churches or places of worship, Yes No
cockpits, horse-racing outlets, public markets, informal settlers, and resettlement areas and
existing/approved PAGCOR-approved gaming establishments
2 Certification on site location distances issued by a licensed geodetic engineer (as applicable)
3 Business Permit;
4 Occupancy Permit
5 Locational clearance
6 Certification issued by Department of Tourism, if proposed site location is a 3-star hotel
7 Fire Safety Inspection Certificate
8 Please check type of establishment (as defined in Annex A - Criteria/Requirements (to be accomplished
for a Gaming Site)
Mall / Arcade by GLDD)
Commercial Building
3-star Hotel / Resort accredited by Department of Tourism
Privately-owned casinos

COMPLIANCE OF SITE TO DISTANCE RESTRICTION GUIDELINES

Name and Address of Institution / Distance COMPLIANT

Establishment Yes No
1 Nearest School/s

2 Nearest Church/es

3 Nearest Cockpit/s

4 Nearest Horse-racing Outlet/s

5 Nearest Public Market/s

6 Nearest Informal Settlers

7 Nearest Resettlement Area/s

8 Nearest Gaming Site/s

(to be accomplished
by GLDD)

COMPLIANCE OF SITE TO SITE LOCATION AREA REQUIREMENTS

Provide a list of currently operating establishments located within the complex/premises of mall/arcade/building where
the proposed gaming site shall be located:
Name of Establishment Type of Establishment
(i.e. retail stores, restaurants, leisure
and entertaiment venues)
1
2
3
4
5
6
7
8
9
10

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 GS Form. No. 38A
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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 I/we are:

a. The same individual or business entity who is the licensed Operator of the existing gaming site.
b. The proposed location of the gaming site is within the same city or municipality as the existing site.
c. The Letter of No Objection (LONO) issued by the Local Government Unit (Unit) for the existing gaming
site address, if any, remains relevant to the new site address. If the existing gaming site has no LONO,
the Operator shall still secure the corresponding LONO for the proposed new location of gaming site.
3 I/We understand that validity of the amended Gaming License (GL) shall be the unexpired term of the
original GL.
4 I/We understand that at this point, PAGCOR does not require any contractual agreement for the
proposed gaming site. Only in the event of PAGCOR's issuance of the amended GL shall I/we execute
such agreement and likewise commence with the renovation of the site. I/We will not hold PAGCOR liable
for any rental/construction expenses that I/we may incur relative thereto.

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
address of the gaming site, should my/our request be approved.

Name: _________________________________________ Signature: _____________________________

APPLICANT or AUTHORIZED REPRESENTATIVE
Date:

EVALUATION
(to be accomplished by GLDD)

A. Site is acceptable in terms of site location, distance requirements and type of establishment (as
declared by the Operator); Acceptability of this site 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. Application is returned due to insufficient requirements/information:
Acknowledged by:

__________________________________ _________________________________________
GLDD EVALUATOR APPLICANT or AUTHORIZED REPRESENTATIVE
Date: Date:

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C. Site is unacceptable due to:

_________ Violation of distance requirement to school/s

_________ Violation of distance requirement to place/s of worship or church/es

_________ Violation of distance requirement to PAGCOR-approved gaming establishments

_________ Violation of distance requirement to cockpits

_________ Violation of distance requirement to horse-racing outlets

_________ Violation of distance requirement to public markets

_________ Violation of distance requirement to informal settlers

_________ Violation of distance requirement to resettlement areas
_________ Not located in prescribed type of establishment
Remarks:
Acknowledged by:
___________________________ _________________________________________
GLDD EVALUATOR APPLICANT or AUTHORIZED REPRESENTATIVE
Date: ____________________ Date: ____________________

D. SUBSEQUENT SUBMISSION OF PAYMENT DOCUMENTS UPON RECEIPT OF GLDD'S SUCCESSSFUL

EVALUATION IN ITEM A ABOVE DATE RECEIVED
by GLDD
Payment Processing Request Form (GS Form No. 2) for PhP40,000.00 Inspection
Fee, if applicable

E. INSPECTION SCHEDULE
Date of Completion of
Pre-Inspection Requirements:
GLDD Processor
Target Date of Inspection:
GLDD Processor
Date of Notification to Applicant
on Inspection Schedule:
GLDD Processor
Actual Date of Inspection:
GLDD Processor
Date of Site Inspection Report:
GLDD Processor
Review of Site Inspection Report
Ok to proceed to Item F below
SM / SRO
For Denial due to:
SM / SRO
F. SCALED FLOOR PLAN AND SITE SET-UP CONCEPT RENDERINGS

Date of Submission GLDD Processor