Application to Change a Dispenser's Data Submission Status

• Instructions:
• Download the form above and provide the information requested
• Mail, fax, or e-mail the completed application to the Wisconsin PDMP:

Department of Safety and Professional Services
Mailing Address: PO Box 8366 Madison WI, 53708-8366
Email: PDMP@wisconsin.gov
Fax: (608) 251-3017