Pennsylvania Gaming Control Board - Office of Compulsive and Problem Gambling

Create Online Account

New Registration

Please complete the form below to provide details for your registration. Completion of the registration process DOES NOT mean you are enrolled in self-exclusion.

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

Enrollee Information

First Name

Middle Name

Last Name

Suffix

Last 4 of SSN

Birth Date

Phone 1

Phone 2 (Optional)

Email Address

Home Address

Address 1

Address 2 (Optional)

Address 3 (Optional)

City

State/Province

Zip/Postal Code

Country/Region