WVCBAPP VOLUNTARY RELINQUISHMENT OF CREDENTIAL AND/OR LICENSE REQUEST

WVCBAPP VOLUNTARY RELINQUISHMENT OF CREDENTIAL AND/OR LICENSE REQUEST

Introduction: This form is for individuals who wish to voluntarily relinquish one or more credentials or licenses issued by the West Virginia Certification Board for Addiction & Prevention Professionals (WVCBAPP).
Please read this form carefully before submitting it.

Relinquishment applies only to the credential(s) or license(s) specifically identified by you on this form. If you hold multiple WVCBAPP credentials or licenses, those not identified for relinquishment will remain unchanged and subject to all applicable requirements.

Voluntary relinquishment does not erase or resolve conduct, complaints, investigations, ethical concerns, or disciplinary matters arising during the period in which a credential or license was held.

NOTICE: WVCBAPP cannot relinquish, surrender, cancel, or otherwise alter a license or credential issued by another board or authority. The credential holder is responsible for contacting that issuing authority directly.
SECTION 1 — IDENTIFYING INFORMATION
Name

PrefixFirst NameMiddle NameLast NameSuffix
Preferred or former names
Type N/A if none
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Upload current PHOTO ID

Cancelof
SECTION 2 — ALL WVCBAPPCREDENTIALS/LICENSES CURRENTLY HELD
Which WVCBAPP credentials or licenses do you currently hold? Select ALL that apply, including credentials/licenses you intend to keep.
SECTION 3 — CREDENTIAL(S)/LICENSE(S)BEING RELINQUISHED
Which WVCBAPP credential(s) or license(s) do you wish to voluntarily relinquish? Select ONLY those you wish to relinquish
Confirmation of Scope of Relinquishment: I understand that I am relinquishing ONLY the WVCBAPP credential(s) or license(s) identified in the question above. Any other WVCBAPP credential or license I hold is not being relinquished through this request.
SECTION 4 — REASON FOR RELINQUISHMENT
What is the PRIMARY reason you are relinquishing the WVCBAPP credential(s) or license(s)?

Other
Please describe why you have chosen to relinquish this credential or license.
Please provide enough information for WVCBAPP to understand the reason for your request.
Have you ever or are you currently voluntarily surrendered or relinquished professional license or credential while a complaint, investigation, disciplinary proceeding, or professional-conduct matter was pending?
SECTION 5 — REQUIRED ACKNOWLEDGMENT
Please acknowledge EACH of the following statements a question. Each statementmust be acknowledged before the form can be submitted.
SECTION 6 — FINAL RELINQUISHMENT REQUEST
I have read and understand the statements above. Voluntarily request relinquishment of the WVCBAPP credential(s) and/or license(s) identified in this form and understand the consequences of this request.
Signature
Date

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

WVCBAPP VOLUNTARY RELINQUISHMENT OF CREDENTIAL AND/OR LICENSE REQUEST

SECTION 1 — IDENTIFYING INFORMATION

SECTION 2 — ALL WVCBAPPCREDENTIALS/LICENSES CURRENTLY HELD

SECTION 3 — CREDENTIAL(S)/LICENSE(S)BEING RELINQUISHED

SECTION 4 — REASON FOR RELINQUISHMENT

SECTION 5 — REQUIRED ACKNOWLEDGMENT

SECTION 6 — FINAL RELINQUISHMENT REQUEST