GMA AUTHORIZE

RE-PRINT RENEWAL NOTICE

So we can can verify your identity we need to know some details from you below:

Game licence No:*

Date of Birth:*

Name

Portal transaction ID

Transaction Type

Concession applied?

NoYes

JSON

Pre-paid on

Title

First Name

Middle Name

Last Name

Gender

Date of Birth

Phone

Mobile

Residential_Line1

Residential_Line2

Residential_Line3

Residential_City

Residential_Postal Code

Residential_State/Proivince

Residential_Country

Use Residential Address as Postal Address

NoYes

Postal_Line1

Postal_Line2

Postal_Line3

Postal_City

Postal_Province/State

Postal_PostalCode

Postal_Country

Attach File