Drug, Device and Cosmetic Program - On-Line User Information

Pennsylvania Department of Health
Drug, Device and Cosmetic Program

Version 4.0.0

On-Line User Information

Please enter some basic information, so that we can identify you.

* Asterisks indicate required fields.

* First Name:

* Last Name:

* Title:

* Telephone:

(Enter all 10 digits of the Phone Number.)

Physical Address:

Physical City:

Physical State:

ZIP:

Email Address:

Complete this section only if a Corporate Personal Identification Number (PIN) has been assigned to your company for multiple registrations/licenses.

Federal ID Number:

PIN:


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