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CLOSING INVENTORY LIST
OF GAMING EQUIPMENT AND Form No. GLDD-943

PARAPHERNALIA FORM Rev. No. 0

Effectivity Sept. 01, 2019

GS Form No. 37 GLDD Reference No.: _________________

Name of Operator: _____________________________________________________________________

(please provide complete registered name)
Gaming Site Location: _____________________________________________________________________
(as reflected in the license)
Type of Game Offering: _______________________________

For gaming site with revoked License, use this form to submit to GLDD and CMED the inventory list of all gaming
equipment and paraphernalia currently located in the gaming site within fifteen (15) days from receipt of notice of
License revocation as required in the post-operational activities of a gaming site.

For gaming site with ceased game offering, use this form to submit to GLDD and CMED the inventory list of all gaming
equipment and paraphernalia pertinent to the ceased game offering within fifteen (15) days from receipt of notice of
approval of cessation of the game offering.

LIST OF GAMING EQUIPMENT/ PARAPHERNALIA FOR DISPOSAL

As of ____________________ (Date of inventory)

PARTICULARS
ITEM SERIAL PAGCOR
MANUFACTURER (Name, Brand or REMARKS
NO. NUMBER TAG NO.
Model)
1
2
3
4
5
6
7
8
9
10
11
12
(Please use separate sheet if necessary.)

We affirm, declare and certify that the above-listed items comprise the total inventory of all gaming equipment
and paraphernalia that are currently located in our gaming site or all gaming equipment and paraphernalia
pertinent to the ceased game offering, as the case may be.
We shall dispose of the above gaming equipment and paraphernalia in accordance with Regulation 15 of the
Gaming Site Regulatory Manual within ninety (90) calendar days from the date of License revocation/ notice of
approval of game offering cessation.
We are aware that should these gaming equipment and paraphernalia, whether declared destroyed, sold,
shipped out or otherwise, are still found under my/our possession after the ninety (90)-day disposal period, we
may be held criminally liable under Philippine laws.

Printed Name: _____________________________________ Signature: _______________

(Authorized Representative)
Position Title: _____________________________________ Date: _______________