HRDD-GEAF-09-04.

revised-102909

PHILIPPINE AMUSEMENT AND GAMING CORPORATION

A Global Corporation with A Global Mindset and A Filipino Heart

GAMING EMPLOYMENT LICENSE APPLICATION FORM

Print legibly. Mark appropriate boxes with "X"
Indicate N/A for ALL spaces which are not applicable
use separate sheet for all information that cannot be accomodated in the spaces provided for

Gaming License No. __________________

LICENSE TYPES AND FEES

OR No. ______________________________

(Choose only one registration type)

NEW

RENEWAL

REAPPLICATION

RECLASSIFICATION

Class A - Local Managerial

Class B - Local Supervisory

Class C - Local Rank & File

Registration Fee --- P5,000.00

Class D - Support Personnel

Registration Fee --- P4,000.00

Class E - Foreign Managerial

Registration Fee --- P2,200.00

Class F - Foreign Non-Managerial

Registration Fee --- P300.00

Registration Fee --- P15,000.00

Registration Fee --- P8,000.00

I. PERSONAL INFORMATION
POSITION APPLIED FOR

SURNAME
FIRST NAME

NAME EXTENSION (e.g. Jr., Sr.)

MIDDLE NAME
DATE OF BIRTH
PRESENT ADDRESS

PLACE OF BIRTH
SEX

CIVIL STATUS

Male
Single
Married

Female
Widowed
Annulled
Separated

ZIP CODE
TELEPHONE NO.

CITIZENSHIP
ACR NO. (Alien Cert. of Reg.)

PERMANENT ADDRESS

HEIGHT (m)
ZIP CODE

WEIGHT (kg)
BLOOD TYPE

TELEPHONE NO.

SSS / GSIS NO.

E-MAIL ADDRESS (if any)

PAG-IBIG ID NO.

CELLPHONE NO. (if any)

PHILHEALTH NO.

TIN

II. FAMILY BACKGROUND

NAME OF CHILD (Write full name and list all)

SPOUSE'S SURNAME

DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME
MIDDLE NAME
OCCUPATION
SPOUSE'S EMPLOYER/
BUSINESS ADDRESS
TELEPHONE NO.
FATHER'S SURNAME
FIRST NAME
MIDDLE NAME
MOTHER'S MAIDEN NAME
FIRST NAME
MIDDLE NAME

III. EDUCATIONAL BACKGROUND

LEVEL

NAME OF SCHOOL
(Write in full)

DEGREE / COURSE
(Write in full)

YEAR
GRADUATED
(if graduated)

HIGHEST GRADE/
LEVEL/
UNITS EARNED
(if not graduated)

INCLUSIVE DATES OF ATTENDANCE

(for undergraduates only)
From

To

SCHOLARSHIP/
ACADEMIC HONORS
RECEIVED

ELEMENTARY

SECONDARY
VOCATIONAL /
TRADE COURSE
COLLEGE

GRADUATE STUDIES
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IV. CAREER SERVICE EXAMINATIONS

CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER
SPECIAL LAWS/ CES/ CSEE

LICENSE (if applicable)

DATE OF
EXAMINATION /
CONFERMENT

RATING

PLACE OF EXAMINATION / CONFERMENT

DATE OF
RELEASE

NUMBER

V. WORK EXPERIENCE (Start from your present employment)

INCLUSIVE DATES
(mm/dd/yyyy)

From

To

DEPARTMENT / AGENCY / OFFICE / COMPANY

(Write in full)

POSITION TITLE
(Write in full)

VI. TRAINING PROGRAMS (Start from the most recent training.)

TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES
(Write in full)

INCLUSIVE DATES OF ATTENDANCE

(mm/dd/yyy)

from

NUMBER OF HOURS

to

CONDUCTED/SPONSORED BY
(write in full)

a. Have you ever been formally charged? If Yes, give details (Use additional sheet if necessary):

YES

NO

YES

NO

c. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by any court or tribunal? If
Yes, give details (Use additional sheet if necessary):

YES

NO

d. Have you ever been separated from the service in any of the following modes: retirement, dismissal, termination or AWOL in the
public or private sector? If Yes, give details (Use additional sheet if necessary):

YES

NO

YES

NO

f. Do you currently posses a gaming license or are you an associated person in any other gaming license? If Yes, indicate license
type and number:

YES

NO

g. Have you ever applied before for a gaming license in this or any other jurisdiction, domestic or foreign, whether or not the
license was ever issued? If yes, explain here (use extra sheet if necessary):

YES

NO

h. Have you ever been denied a gaming license, withdrawn a gaming license application or had any disciplinary action taken
against any gaming license that you have held, either individually or as part of an ownership group, in this or any jurisdiction?

YES

NO

b. Have you ever been guilty of any administrative offense? If Yes, give details (Use additional sheet if necessary):

e. Do you have any relative working in PAGCOR or in any of its licensee? If Yes, give details:

VII. FINANCIAL HISTORY (for Managerial license applicants only)

1. Are you delinquent in the filing of any tax return with any taxing agency anywhere?

YES*

NO

2. Are you delinquent in the payment of any taxes, interest, or penalties due to any taxing agency anywhere?

YES*

NO

3. Are you delinquent in the payment of any judgements due to any governmental agency anywhere?

YES*

NO

4. Are you delinquent in the repayment of any government-insured loans?

YES*

NO

*if you answered YES to any of the questions above, give details on separate sheet and include any items currently under formal dispute or legal appeal. Attach any documents to prove your
settlement on this issue.
NOTICE: If you answered YES to any of the questions above, you must provide proof you have taken steps to resolve the financial delinquency before being issued a PAGCOR gaming
li
I declare under oath and penalty of perjury that the foregoing information are true and correct. I also authorize PAGCOR and/or any of its authorized representative to verify / validate
the contents stated herein.

RightThumbmark

Signature
(Affix signature WITHIN THE BOX. Use BLACK SIGNPEN)

2X2 Picture
withwhitebackground
(scannedpicturesnot
allowed)

Date Accomplished
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