Pennsylvania Gaming Control Board - Office of Compulsive and Problem Gambling

Create Online Account

New Account

Please complete the form below to provide details for your account.

ATTENTION
Please enter your name exactly as it is listed on your government-issued ID.

Enrollee Information

First Name

Middle Name

Last Name

Your name MUST match your government-issued ID or your request could be denied.

Suffix (Optional)

Last 4 of SSN

Birth Date

Phone 1

Phone 2 (Optional)

Email Address

Home Address

Street Address

Apartment, suite, etc. (Optional)

PO Box (Optional)

City

State/Province

Zip/Postal Code

Country/Region

Mailing Address

My mailing address is the same as my home address.

Street Address

Apartment, suite, etc. (Optional)

PO Box (Optional)

City

State/Province

Zip/Postal Code

Country/Region

ATTENTION
Completion of the registration process DOES NOT mean you are enrolled in self-exclusion. Please ensure that your data is accurate. Registrations may be rejected if inaccuracies are found.