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PAYMENT PROCESSING Form No. GLDD-917
REQUEST FORM
For Bingo, Electronic and Poker Games Rev. No. 0
Effectivity Sept. 01, 2019

GS Form No. 2
Use this form to transmit payment/s for fees/financial requirements due to PAGCOR. Only request forms with correct
and complete information and supporting documents will be processed. Failure to provide correct and complete
information could result in non-processing of this request.

SECTION A: PAYMENT INFORMATION / DETAILS (TO BE FILLED UP BY SERVICE PROVIDER / APPLICANT / OPERATOR)

Operator/Applicant/Service Provider (Payor): _________________________________________

Office Address: ______________________________________________________________
Site Address: ______________________________________________________________
TIN No.: _____________________

Payment Mode:  Cash  Check/s

Check Details:
Check No.* Amount* Date* Name of Bank & Branch*

*please use separate sheet if necessary

Payment Details:
Bingo Electronic Betting Sports
No. Particulars Poker Others Amount Remarks**
Games Games Exchange Betting
1 Application Fee
2 Processing Fee
3 Inspection Fee
4 Renewal Fee
5 ExtensionFee
6 Accreditation Fee
Performance Cash
7
Deposit/Cash Bond
8
Penalty / Demerits
GLDD Ref. No.:________

9 Others
TOTAL
**Please indicate in the Remarks column the specific game offering, No. of Extension and GL No., as applicable.

By:____________________________________ Date: __________________________

(signature over printed name)

Note: 1) Please fill up also for deposits made to PAGCOR OPEX Account.
2) It is understood that Check payments shall be subject to three (3)-day clearing
3) In the event that a check is returned by the bank due to insufficient funds or any other reason, the Operator shall settle the arrears in cash or by
issuing a Manager’s Check.

SECTION B: SUBMISSION INSTRUCTIONS

Once Section A is completed, please submit this form together
with supporting payment document/s as indicated below: Please indicate the name of the Operator/Applicant and site
For cash/check payments, please proceed to: location address on the deposit slip and email along with this GS
Form No. 2 within twenty four (24) hours to:
Gaming Licensing and Development Department
Philippine Amusement and Gaming Corporation JoseNoel.Vega@pagcor.ph and
PAGCOR Main Corporate Office, 12th Floor, iMET BPO Tower, gldd.rgulicensing@pagcor.ph
CBP-1A Metropolitan Park, Roxas Boulevard, Pasay City 1300 (for gaming site application, accreditation application and/or renewal of
Tel. Nos. : 755-3199/755-3299/755-3899/755-3999 license)
loc. 5012, 5013, 5014 or 5015 gldd.rgucompliance@pagcor.ph
(for Performance Cash Deposit/s, penalty/ies and demerit/s)
For deposits to PAGCOR Opex Account, here are the
bank details:
Account Name: PAGCOR OPEX Fund
Account no: C/A No. 3402-1036-70
Land Bank Branch: LBP Plaza, Malate, Manila