CONFIDENTIAL

Cagayan Economic Zone & Free Port

Republic of the Philippines

INTERACTIVE GAMING LICENCE

APPLICATION FORM
Pursuant to the
Interactive Gaming Act 2003
Form Number CEZA-003

Applicants Name: ___________________________________________________

Company Number: ___________________________________________________
Registered Office: ___________________________________________________
___________________________________________________
Postal Address:

___________________________________________________
___________________________________________________

Address of Proposed Premises: _________________________________________

___________________________________________________
Telephone Number:___________________________
Facsimile Number: ___________________________
Email Address:

___________________________

Contact Name:

___________________________

License Application Form

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Version: 1.0

DECLARATION (if applicable):

In the case of a Company/Body Corporate, I/we certify that I/we am/are duly
authorised to make the application on behalf of the Company/Body Corporate.
Executed under the common seal of
______________________________________________________
(If applicable)

(Name of Company/Body Corporate)

Signature:

_____________________________________

Name:

_____________________________________

(Seal)

(Please Print)

This application must be accompanied by:

a completed Company Probity Form (if applicable) in respect of the
applicant;
a completed Personal Probity Form at least in respect of each company
director, the company secretary and the chief executive officer; and
the prescribed fee; and
A copy of your Business Plan; and
A signed copy of the Industry Code of Practice.
Applicant Signature:

_____________

Date:

_____ / _____ / _____

In the presence of:

____________________
(Signature of Witness)
Name of Witness: ___________________
Address of Witness:___________________
___________________
___________________

Note:
If an applicant attempts to obtain an Interactive Gaming Licence by a materially false or misleading representation
or in some other improper way, this will impact when assessing the suitability of the applicant. Further, section 4
of the Interactive Gaming Act (2003) provides that if an Interactive Gaming Licence is obtained by a materially
false or misleading representation, or in some other improper way, this is a ground for suspending or cancelling
the licence.
The completed application form, fee and attachments should be forwarded to:
The Regulator of Interactive Gaming
Cagayan Economic Zone & Free Port
th
26 Floor, West Tower
Philippine Stock Exchange Centre
Exchange Road, Ortigas Centre
Pasig City 1605, Philippines

License Application Form

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Version: 1.0