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GS Form No. 2 - Payment Processing Request Form

This document is a payment processing request form used to transmit payments for fees and financial requirements due to PAGCOR for bingo, electronic, and poker games. It requires information about the operator/applicant including payment details, mode, and amount. Once completed, the form must be submitted along with supporting payment documents to the Gaming Licensing and Development Department at PAGCOR's main office.

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JP De La Peña
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1K views1 page

GS Form No. 2 - Payment Processing Request Form

This document is a payment processing request form used to transmit payments for fees and financial requirements due to PAGCOR for bingo, electronic, and poker games. It requires information about the operator/applicant including payment details, mode, and amount. Once completed, the form must be submitted along with supporting payment documents to the Gaming Licensing and Development Department at PAGCOR's main office.

Uploaded by

JP De La Peña
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
  • Payment Processing Request Form: A form used to request payment processing for Bingo, Electronic, and Poker games, including details for the operator and payment methods.

Page No.

Page 1 of 1
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 [email protected] and
PAGCOR Main Corporate Office, 12th Floor, iMET BPO Tower, [email protected]
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 [email protected]
(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

PAYMENT PROCESSING REQUEST FORM For Bingo, Electronic and Poker Games Page No. Page 1 of 1 Form No. GLDD-917 Rev. No

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