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Ecan Zoning Certification
PCSD application form for ecan zoning certification
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: GAB-RAC-APPLic
HORSE RACING BETTING
SUPERVISION DIVISION
GAMES AND AMUSEMENTS BOARD
1 1/2in x 1 1/2in
Photo
2/F Legaspi Towers 200, Paseo de Roxas
Makati City, Tel. No. (632) 813-57-93
APPLICATION FOR LICENSE
NEW
RENEWAL
License Applied For : _________________________________
PERSONAL INFORMATION
Name: ____________________________________________________Nick Name/Alias_________________________
(Surname)
(First Name)
(M.I.)
Home Address: ____________________________________________________________________________________
Office Address: __________________________________________________ Tel. No. __________________________
Date of Birth: _________________________Place of Birth: ________________________________________________
Citizenship: _______________Civil Status:______________ Age: ___________Height: ________Weight: ___________
Company/Club: ___________________________________________________________________________________
Have you been accused or convicted of any crime? (If yes, state the nature of offense)
Date: _______________________
____________________________
(APPLICANT'S SIGNATURE)
REQUIREMENTS
1 1/2 x 1 1/2 colored ID PICTURE (White background)
Medical requirement (Fit To Work)
Processed By:
_____________________________________
SIGNATURE OVER PRINTED NAME
Date: _______________________________
Noted by:
___________________________________
GAB Physician/ Medical Officer
Bill No: ______________ Date:______________
License Fee: ______________
LRF:
______________
Penalty:
______________
Total:
______________
O.R. No. ______________
Cashier: ______________
RECOMMENDING APPROVAL:
MARISSA B. SO
OIC, Horse Racing Betting Supervision
APPROVED BY:
OFELINA C. RETARDO
Chief Administrative Officer
