PDD Authorization Application

IED Portal

An Official Pennsylvania Government Website

Step 1 of 8

PDD Authorization Application

Required fields are marked with an asterisk.(*)

Applicant Information

Applicant's First Name

*

Applicant's Last Name

*

Address

*

City

*

State

Zip Code

*

Mailing address (if different)

Mailing address

*

Mailing Address City

*

Mailing Address State

Mailing Zip Code

*

Principal Point of Contact

First Name

*

Last Name

*

Title

*

Telephone Number (+1-XXX-XXX-XXXX)

*

Email Address

**

Emergency Contact (if different from Principal Point of Contact)

First Name

*

Last Name

*

Title

*

Telephone Number (+1-XXX-XXX-XXXX)

*

Email Address

**