Yellow Dot Participation

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An Official Pennsylvania Government Website

Yellow Dot Participation

Section I.
Required fields are marked with an asterisk.(*)

A Yellow Dot kit can be mailed to you by submitting the participation form below. For large quantities, please contact the PennDOT Sales Store at ra-penndotsalesstore@pa.gov or 717-787-6746. Due to the large volume of kit requests, please allow a few weeks for delivery. All requests are given priority based on availability of supplies. PLEASE NOTE: Only one packet is needed per vehicle. Do not submit this form multiple times for participants living in the same household. If you have multiple participants riding in the same vehicle, each should insert a medical information sheet (PDF) into a single packet.

Section II.

First Name

Last Name

Section III.

Address 1

Address 2

City

State

Zip Code

Section IV.

Email Address

Confirm Email Address

Phone Type

Phone Number (XXX-XXX-XXXX)

Section V.

Number of Packets (One per vehicle)

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