PHILIPPINE AMUSEMENT AND GAMING CORPORATION

A Sure Bet for Progress in Gaming, Entertainment and Nation Building GS FORM NO. 11
(v.1.3) 06.14.2017
GLDD Reference No.: _____________

SHIPMENT CLEARANCE REQUEST AND APPROVAL FORM

Use this form to request shipment clearance from PAGCOR on importations of gaming equipment and/or paraphernalia
necessary for the gaming site operations. Only requests with correct, complete information and documentary
requirements will be processed. Applications with incorrect and/or incomplete information will be returned. Cut-off for
submission of requests shall be 4:00 P.M.

PLEASE ALLOW 14 BUSINESS DAYS FOR GLDD TO PROCESS YOUR REQUEST.

SECTION A: SHIPMENT CLEARANCE REQUEST (TO BE FILLED UP BY OPERATOR)
This is to request Gaming Machine(s)/Terminal(s) Chips/Plaques
approval to pull-out Gaming Machine/Terminal Assembly Parts/Peripherals Bill Validator(s)/Acceptor(s)
and transfer: Bingo/Gaming System(s) Electronic Bingo Card Daubers
(Put an [x] mark on Bingo System Component Part(s)/Paraphernalia Game Conversion Kit(s)
any of the Gaming Table(s) Gaming/Bingo Cards
following) Table Layout(s) Others __________________
Description:
Purpose/Use of Item: gaming site stocks/spare warranty/replacement
Gaming Site Location/Operator’s Storage Area:
SECTION A.1.: FOR IMPORTATIONS OF ELECTRONIC GAMING MACHINE(S), GAME CONVERSION KIT(S) OR
ELECTRONIC GAMING SYSTEM(S) (TO BE FILLED UP BY OPERATOR)
We are submitting the accompanying Certification/s from International Gaming Laboratory duly recognized by PAGCOR for the following:
Electronic Gaming/Bingo Machine(s) Electronic Gaming/Bingo System(s)
Game Conversion Kit(s) None (Certification/s already submitted)

SECTION A.2: CUSTOMS AND DUTIES EXEMPTION/TAXES (TO BE FILLED UP BY OPERATOR)

Importation of the abovementioned Subject Item(s) is/are:
Duty/Tax Free privileges covered under Import Permits filed by Operator with ____________________.
Customs and duties taxes for the account of the Operator.

Shipping Documents Attached: Commercial Invoice No.

(Put an [X] mark on any of the following) Pro-forma Invoice No.
Tax Invoice No.
Supplier’s Name:
Address :
Supplier’s GLDD Enrollment No.
Shipment Point of Origin : Name of Broker :

SECTION B: TERMS AND CONDITIONS

 Gaming machines/terminals, gaming systems and game conversion kits must undergo a prior evaluation and approval by PAGCOR,
before an Operator may request shipment clearance for importation of the same, otherwise, the request for shipment clearance shall
be rejected by GLDD.
 A supplier of gaming machines, systems and all other gaming equipment and paraphernalia to be used in gaming site must be
enrolled with GLDD and accredited by Operator/s. A shipment clearance request on importation from a Supplier who is not GLDD-
enrolled and Operator-accredited shall be rejected.
 If approval is granted by GLDD on the shipment request, Operator shall ensure that all items shipped shall be strictly within the
quantities and description indicated in the GLDD approved shipping documents.
 Before the shipment is turned over to the Operator, a representative from Compliance Monitoring and Enforcement Department
(CMED) [for bingo sites] and Service Provider [for non-bingo sites] shall conduct an inspection and inventory on the same.
 Any subsequent movements of said item/s shall require approval of CMED (for bingo sites) or GLDD (for non-bingo sites) prior to
implementation.

This is to certify that the aforementioned are true, correct, complete and consistent with the attached shipping
documents. In addition, we hereby agree to abide by the terms and conditions under Section B above.

Authorized Signatory: Signature :

Position Title : Date:
Operator’s Name: ____________________________
 GLDD Reference No.: _____________
SECTION C: SUBMISSION INSTRUCTIONS

Once Section A and Section B are completed, please submit this form to GLDD along with the necessary attachments.
Hard copies may be submitted directly to the GLDD office or scanned copies of the documents may be emailed using the
e-mail addresses indicated below:

Gaming Licensing and Development Department E-mail address:

Philippine Amusement and Gaming Corporation gldd.rgucompliance@pagcor.ph
rd
3 Floor PAGCOR House, 1330 Roxas Boulevard, Ermita, Manila
Tel. Nos. 522-3429 / 521-1542 loc. 336 or 348

If submission of this approval form is done thru e-mail, the Operator should ensure that it has been duly received and
acknowledged by GLDD. The Operator shall be notified thru e-mail confirming receipt of this approval form. If no e-mail
confirmation is received, the Operator should submit the hard copy of the approval form directly to GLDD.

SECTION D: ACTION TAKEN (TO BE FILLED UP BY GLDD)

A. RETURNED due to the following reasons:
Incomplete information and/or supporting shipping documents
Incorrect information vis-à-vis supporting shipping documents
Supplier is not GLDD-enrolled
No prior review of proposed importation
No Certifications from Int’l Gaming Laboratory duly recognized by PAGCOR attached [for Electronic
Gaming/ Bingo Machine(s), Game Conversion Kit(s) or Electronic Gaming/ bingo System(s)]

B. RECEIVED FOR PROCESSING with assigned Reference No. ________________

By: Printed Name: ______________________________ Signature: ________________________
Position Title: ______________________________ Date: ________________________

C. RECOMMENDATION FOR APPROVAL

By: Printed Name: ______________________________ Signature: ________________________
Position Title: ______________________________ Date: ________________________
Approved by:

Assistant Vice President

(Head of Evaluating Department)

For endorsement to CMED:

INSPECTION AND INVENTORY OF SHIPMENT FOR BINGO SITES

TO : THE ASST. VICE PRESIDENT, CMED

Requesting for the following:
1. A representative from CMED together with the Operator, to conduct a joint inspection and inventory of the Subject
Item/s in order to verify that item/s shipped is/are within the approved shipping documents and for inventory
purposes, before the same are turned over to the Operator.

2. CMED ensures that item/s shipped is/are used according to the intended purpose.