PHILIPPINE AMUSEMENT AND GAMING CORPORATION
A Sure Bet for Progress in Gaming, Entertainment and Nation
Building
GS FORM NO. 14
(v.1) 06.01.2015
GLDD Reference No.: _____________
PULL-OUT AND TRANSFER OF GAMING EQUIPMENT
NOTIFICATION FORM
(Gaming Site to Supplier’s Storage Area or vice versa)
Use this form to notify PAGCOR of pullout and/or transfer of gaming equipment and/or paraphernalia from
PAGCOR-approved gaming site to Supplier or vice versa. Please accomplish this form by providing correct
and complete information. The Operator shall submit this form to GLDD at least one (1) business day prior
to intended date of implementation.
PLEASE NOTE THAT PAGCOR RESERVES THE RIGHT TO CONDUCT POST-AUDIT OF THE GAMING
EQUIPMENT WHICH HAS BEEN PULLED OUT FROM PAGCOR-APPROVED GAMING SITE FOR TRANSFER TO
THE SUPPLIER OR VICE VERSA.
Name of Operator :
Gaming Site Location:
Date of Implementation :
SECTION A: PROPOSED PULLOUT AND TRANSFER OF GAMING EQUIPMENT
(TO BE PROVIDED BY OPERATOR)
Please be informed of the pullout and transfer:
from the Supplier’s storage area to abovementioned Gaming Site
from the Operator’s Gaming Site to the Supplier’s storage area
from the Operator’s storage area to the Supplier’s storage area
of the following gaming equipment:
Gaming Machine(s)/Terminal(s)
Bingo Equipment/Paraphernalia
Gaming Machine/Terminal Assembly Part(s)
Bill Validator(s)/Acceptor(s)
Gaming Machine/Terminal Peripherals/Accessories
Progressive Jackpot System(s)
Electronic Bingo Machine(s)/Terminal(s)
Game Conversion Kit(s)
Electronic Bingo Machine/Terminal Assembly Part(s)
Electronic Bingo Management System(s)
Electronic Bingo Machine/Terminal Peripherals/Accessories
Transmitter(s)/Receiver(s)/Hub(s)
Bingo/Gaming System(s)
Electronic Bingo Card Daubers
Bingo System Component Part(s)
Others ___________________
No. of machines/terminals to be pulled-out from the gaming site: ___________
No. of machines/terminals at the gaming site after pull-out:
___________
No. of machines/terminals to be delivered by the Supplier:
___________
Attachment:
Inventory list of items for Pullout and Transfer from/to Supplier
Description of Subject Item(s):
Reason for Pullout and Transfer:
Origin:
Destination:
____________________________
Operator’s Authorized Signatory
(Signature over printed name)
____________________
Date
GLDD Reference No.: _____________
Request for pull-out/transfer from/to Supplier of item/s should be accompanied by Confirmation of
Accountability duly filled up and signed by Operator or Supplier, as applicable. Operator should
request their Supplier to accomplish Section B of this form, as the case may be.
SECTION B: CONFIRMATION OF ACCOUNTABILITY (TO BE FILLED UP BY OPERATOR OR SUPPLIER, as applicable)
hereby ASSUMES RESPONSIBILITY/ACCOUNTABILITY
(Name of Receiving Party)
for the abovementioned items that will be pulled-out from the ______________________________ upon
(Origin)
transfer of the same to _________________________________________.
(Destination)
Further, our office/warehouse is available to PAGCOR for inspection and inventory of gaming machines,
equipment and paraphernalia at anytime that may be deemed necessary by PAGCOR.
By:
________________________________
Authorized Signatory of Receiving Party
_______________________
Date
(Signature over Printed Name)
Name of Supplier:
Supplier’s Enrolment No.:
Supplier’s Permit to Possess No.:
Supplier’s Storage Area Location:
We confirm and undertake to do the following:
a. The conduct of inspection and inventory prior to the pullout/transfer of the gaming equipment and
other related items from/to PAGCOR-approved gaming site to/from the Supplier, which shall be
coordinated with the Compliance Monitoring and Enforcement Department (CMED).
b. Submission to GLDD of a log report of all gaming equipment transferred to/from the gaming site
commencing from the first day up to the last day of the calendar month no later than the 10th day of
the succeeding month.
c. Submission of an Annual Inventory Report on or before January 10 of the succeeding year, of all
gaming equipment stored in the Operator’s storage area and deployed in the gaming site.
d. The conduct of pullout and transfer from/to Supplier of gaming equipment is compliant with the
requirements set forth in the procedures and guidelines for transfer of gaming equipment from/to
PAGCOR-approved gaming site to/from the Supplier.
Name of Requestor :
Signature :
(Operator)
Position Title :
Date:
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
Philippine Amusement and Gaming Corporation
3rd Floor PAGCOR House, 1330 Roxas Boulevard, Ermita, Manila
Tel. Nos. 522-3429 / 521-1542 loc. 336 or 348
E-mail addresses:
[email protected]
[email protected]
If submission of this notification 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 by GLDD thru e-mail confirming receipt
of this notification form. If no e-mail confirmation is received from GLDD, the Operator should submit the
hard copy of the notification form directly to GLDD.
SECTION D: ACKNOWLEDGEMENT OF NOTIFICATION (TO BE FILLED UP BY GLDD)
RECEIVED with REFERENCE NO. _________________
By:
Printed Name:
Position Title:
Signature:
Date:
Attachment:
INVENTORY LIST OF ITEMS FOR PULL-OUT/TRANSFER
FROM/TO SUPPLIER
NO.
MANUFACTURER
PARTICULARS*
SERIAL NO.
PAGCOR TAG
NO.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
*Under particulars, please indicate Game Name, Brand and Model, if applicable.
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