Demographics Records Update Form

West Virginia Certification Board for
Addiction and Prevention Professionals
436 12th Street Suite C, Dunbar, WV 25064
Phone 304-768-2942
Email: wvcbapp@wvcbapp.org
Demographics Records Update Form

Please fill out your personal data below.
Before You Begin the Application

Ensure that all required documents are completed and available in one of the following formats: PDF, DOC, DOCX, XLS, XLSX, CSV, TXT, RTF, HTML, ZIP, MP3, WMA, MPG, FLV, AVI, JPG, JPEG, PNG, GIF.

If you do not see a "Thank You" page and receive an email copy after selecting "Submit," it did not submit.
Name

PrefixFirst NameMiddle NameLast NameSuffix
What information has changed?
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Certification(s) Held
Example: AADC, etc.
Certification Number(s)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you wish to have a new certificate printed and mailed?
If you are requesting a new/updated certificate, how will you be paying the fee?
If you are requesting a name change, please upload court order of divorce, marriage license, or other legal form showing the change.

Cancelof
If you are requesting a name change, please upload your new photo ID.

Cancelof
Payment for New Certificate: optional
prevnext( X )
New Certificate Fee

$20.00

Total

$0.00
If using PayPal for payment, what is the name or agency the account is under?
I affirm that the information contained in this application is true.
Signature
Date

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

Demographics Records Update Form

Payment for New Certificate: optional