Pennsylvania Gaming Control Board - Office of Compulsive and Problem Gambling

Self-Exclusion Enrollment and Removal

New Registration

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

Enrollee Information

First Name

Last Name

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

Mailing Address

Check if Mailing Address is the same.

Address 1

Address 2 (Optional)

Address 3 (Optional)

City

State/Province

Zip/Postal Code

Country/Region

Physical Chartacteristics

Sex as listed on your government issued photo identification

Gender Identity

Height (ft.)

Height (in.)

Hair Color

Eye Color

Ethnicity

Distinguishing Marks (Optional)