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GS Form No. 23 - Certificate of Gaming Equipment - Paraphernalia Destruction Form

1) The document is a certificate for the destruction of gaming equipment and paraphernalia that must be completed after destruction. 2) It lists the operator's name and gaming site location and requires a description and quantities of destroyed items. 3) The operator affirms the equipment has been permanently destroyed and made unusable for gaming and acknowledges legal liability if any destroyed items are found operating or in their possession after 90 days.

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JP De La Peña
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254 views2 pages

GS Form No. 23 - Certificate of Gaming Equipment - Paraphernalia Destruction Form

1) The document is a certificate for the destruction of gaming equipment and paraphernalia that must be completed after destruction. 2) It lists the operator's name and gaming site location and requires a description and quantities of destroyed items. 3) The operator affirms the equipment has been permanently destroyed and made unusable for gaming and acknowledges legal liability if any destroyed items are found operating or in their possession after 90 days.

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.
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Download as PDF, TXT or read online on Scribd
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CERTIFICATE OF GAMING Page No.

Page 1 of 2

EQUIPMENT/ Form No. GLDD-932


PARAPHERNALIA Rev. No. 0
DESTRUCTION FORM Effectivity Sept. 01, 2019

GS Form No. 23 CMED Reference No.: _________________

Name of Operator: ______________________________________________________________________


(please provide complete registered name)
Gaming Site Location: ______________________________________________________________________
(as reflected in the license)
Type of Game Offering: _______________________________
Location of Destruction of Gaming Equipment/Paraphernalia: ______________________________________
Date of Destruction of Gaming Equipment/Paraphernalia: ______________________________________
Notified using GS Form No. 22 with CMED Reference No. ______________________________
(For operational gaming site only)

Use this form after destruction of gaming equipment/paraphernalia has been completed. Use additional form for
another set of gaming equipment/paraphernalia. The Operator with revoked license shall dispose of its gaming
equipment/paraphernalia within ninety (90) calendar days from the date of license revocation.

LIST OF GAMING EQUIPMENT/ PARAPHERNALIA FOR DESTRUCTION


ITEM DESCRIPTION
MODEL/CODE QUANTITY
NO. (Name of Supplier, Size, Shape, Colors, etc.)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
(Please use separate sheet if necessary.)

We affirm, declare and certify that the abovementioned gaming equipment/paraphernalia are permanently
destroyed and rendered unusable for gaming operations.
We are aware that should these gaming equipment/paraphernalia are found to be operating illegally (for
operational gaming sites) or found under our possession, whether declared destroyed, sold, shipped out or
otherwise, after the ninety (90)-day disposal period (for gaming sites with revoked Licenses), we may be held
criminally liable under Philippine laws.

____________________________________________ _____________________
Printed Name and Signature of Date
Operator or Authorized Representative, Designation
CERTIFICATE OF GAMING Page No. Page 2 of 2

EQUIPMENT/ Form No. GLDD-932


PARAPHERNALIA Rev. No. 0
DESTRUCTION FORM Effectivity Sept. 01, 2019

REPUBLIC OF THE PHILIPPINES )


CITY/ MUNIPALITY OF _________ ) S.S.

I, after being duly sworn to in accordance with law, hereby depose and state, that the above certification,
including declarations therein, affirming the destruction of above-listed gaming equipment/ paraphernalia is true
and correct.

________________________________________________
Signature of Operator/ Authorized Representative

Government Issued ID: _____________________________


ID No.: _____________________________
Date Issued: _____________________________

SUBSCRIBED AND SWORN to before me this _____ day of ______________, 20__, in the City/ Municipality of
__________________, affiant exhibiting to me the above-stated government-issued identification card.

_____________________________
(Notary Public)

Doc. No. _______


Page No. _______
Book No. _______
Series of 20 ____

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