Replacement Certificate or Card

Replacement Certificate or Card

Use this form to request a replacement certificate or card.
Name

First NameLast Name
Is this a name change?
Demographic Change Form Link:

https://form.jotform.com/250314777820154
Former Name if this is a name change:

First NameLast Name
If this is a name change, upload new ID and supporting legal documents showing the name change. You will need to fill out a demographics change form as well.

ID, marriage certificate, divorce decree, etc.
Cancelof
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Certificate Number
Which credential's certificate do you need replaced?
AADC, ADC, PRSS-MH/SUD etc.
What do you need replaced?
How will you be paying the replacement fee?
Certificate or Card Replacement Fee
prevnext( X )
Certificate/Card Replacement Fee
Pay here via PayPal or mail a check or money order to WVCBAPP for 20.00

$20.00

Total

$0.00
Name or agency on the PayPal account
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: