APPLICANT NAME: _______________________________________________________________________

PROPOSED OUTLET SITE: _________________________________________________________________

SKETCH/LOCATION MAP OF THE PROPOSED SITE

Please draw a directional sketch and attach pictures of the proposed site / Google Map indicating main streets, side
streets and landmarks.
(Iguhit sa ibaba ang sketch ng lugar at mag lakip ng larawan / Google Map na may nakalagay na pangunahing
kalsada, tabing kalsada at ang mga pook palatandaan)
 INDIVIDUAL APPLICATION

APPLICANT INFORMATION SHEET

APPLICANT’S NAME (Last Name, First Name, Middle Name

Permanent Home Address with Zip Code or Address Currently Staying: Contact Details
Landline

Mobile

Email

Date of Birth (mm/dd/yy) Age Place of Birth

Gender Civil Status Nationality

Others,
Male Female Single Married
Specify

Application Tax Identification No. (TIN)

New Renewal

Are you related by consanguinity or affinity to any PCSO If YES, give details: _______________
Officials/Employees? Kindly specify degree (ex. 1st, 2nd or Yes
3rd degree) No
Do you have any interest in a corporation that owns and If YES, give details: _________________
operates Lotto outlets? Yes

Do you have any relative (by consanguinity or affinity)
owning/ operating an existing Lotto outlet?
No
If YES, Name: ______________________
Yes Relationship: ______________________
How many outlets: ___________________
No Location(s): _________________________

Do you have existing Lotto outlet/s? If YES, how many? ____________

Yes Location(s): __________________

No
Have you ever been convicted of estafa or theft? Yes If YES, give details: __________________

No

References (person not related by consanguinity or affinity)

Name Address Contact Number
 For purposes of succession, kindly indicate designated recipient (must be within 2nd degree of
consanguinity or affinity) of Lotto agency:
NAME ADDRESS CONTACT NUMBER

ID picture taken within the last

six months
(Size: 2x2)

RIGHT
THUMBMARK

ACKNOWLEDGEMENT

I hereby:

1. Affirm that:
1.1 I have read, understood and accept the criteria, procedure, requirements, conditions and the information
for this application; and
1.2 All the information given in this application is true and correct with my own personal knowledge.
2. I understand that PCSO has the discretion to accept or reject my application upon:
2.1 Discovery of any falsehood or inconsistencies in the information or documents submitted or non-
compliance with the stated procedures shall result in the outright denial or rejection of the application or,
if already granted, may result the cancellation of the application thereof;
2.2 The approval of this application is purely discretionary on the part of PCSO;
3. I understand that the application fee is non-refundable.
4. All communication to the applicant will be directed to the mailing address / e-mail address / contact number
indicated on this form. PCSO must be notified immediately of any changes in address.

Date Accomplished Signature over Printed Name