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Protection From Abuse Database
User Account Request Form

Please complete this form if you would like to have a PFAD User Account assigned.

Your Name:	First Middle Last Suffix (Jr, Sr, etc.)
Job Title:
Organization/Office:
Address:
City:
State:	Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington West Virginia Wisconsin Wyoming Puerto Rico Guam
ZipCode:
Pennsylvania County:	<< Pennsylvania Statewide>> << Outside Pennsylvania >> Adams Allegheny Armstrong Beaver Bedford Berks Blair Bradford Bucks Butler Cambria Cameron Carbon Centre Chester Clarion Clearfield Clinton Columbia Crawford Cumberland Dauphin Delaware Elk Erie Fayette Forest Franklin Fulton Greene Huntingdon Indiana Jefferson Juniata Lackwanna Lancaster Lawrence Lebanon Lehigh Luzerne Lycoming Mckean Mercer Mifflin Monroe Montgomery Montour Northampton Northumberland Perry Philadelphia Pike Potter Schuylkill Snyder Somerset Sullivan Susquehanna Tioga Union Venango Warren Washington Wayne Westmoreland Wyoming York
Phone Number:
Email Address:
I qualify for an account because I work in the following type of office:
	Prothonotary Clerk of Court Domestic Violence Program Legal Services PFA Coordinator District Justice Office Trial Judge or Court Personnel Law Enforcement Probation / Parole District Attorney's Office Public Defender's Office Private Attorney
If you chose "Private Attorney" above, please enter your Attorney ID Number:
Your Supervisor's name:
Supervisor's Phone #:

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