WVTA Member Information Change Form

WEST VIRGINIA TROOPERS ASSOCIATION

MEMBER INFORMATION CHANGE FORM
Member name*

First NameLast Name
Member cell phone number*
Please enter a valid phone number.
Member email address*
example@example.com
What type of change do you need to make? Please select one.*

Name changeHome address changePhone number changeEmail address changeWork title changeTroop number changeLife insurance beneficiary changeMembership dues payment method change
Effective date of change*

MonthDayYear
Date
Former name*

First NameLast Name
New name*

First NameLast Name
Current home address*

Street Address

Street Address Line 2

CityState

Zip Code
New home address*

Street Address

Street Address Line 2

CityState

Zip Code
New phone number
Please enter a valid phone number.
HomeCellWork
New email address*
example@example.com
New work title*

State trooperRetired state trooper
West Virginia county*
New troop number*
Work location (address)*

Street Address

Street Address Line 2

CityState

Zip Code
Retirement date*

MonthDayYear
Date
New life insurance beneficiary*

First NameLast Name
Relationship*
New beneficiary date of birth*

MonthDayYear
Date
New beneficiary home address*

Street Address

Street Address Line 2

CityState

Zip Code
New beneficiary cell phone*
Please enter a valid phone number.
New membership dues payment method type*

Credit card (CC)Bank account (ACH)
If you need to change your membership dues payment method information for any reason - for example - new CC number, new CC expiration date, switch from ACH to CC, or visa versa). Please email the WVTA local at wvtaoffice@aol.com and we will contact you directly to expedite the process.
Do you have any additional changes?*

YesNo
What other type of change do you need to make? Please select one.*

Name changeHome address changePhone number changeEmail address changeWork title changeTroop number changeLife insurance beneficiary changeMembership dues payment method change
Effective date of change*

MonthDayYear
Date
Former name*

First NameLast Name
New name*

First NameLast Name
Current home address*

Street Address

Street Address Line 2

CityState

Zip Code
New home address*

Street Address

Street Address Line 2

CityState

Zip Code
New phone number
Please enter a valid phone number.
HomeCellWork
New email address*
example@example.com
New work title*

State trooperRetired state trooper
West Virginia county*
New troop number*
Work location (address)*

Street Address

Street Address Line 2

CityState

Zip Code
Retirement date*

MonthDayYear
Date
New life insurance beneficiary*

First NameLast Name
Relationship*
New beneficiary date of birth*

MonthDayYear
Date
New beneficiary home address*

Street Address

Street Address Line 2

CityState

Zip Code
New beneficiary cell phone*
Please enter a valid phone number.
New membership dues payment method type*

Credit card (CC)Bank account (ACH)
If you need to change your membership dues payment method information for any reason - for example - new CC number, new CC expiration date, switch from ACH to CC, or visa versa). Please email the WVTA local at wvtaoffice@aol.com and we will contact you directly to expedite the process.
Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty:

WEST VIRGINIA TROOPERS ASSOCIATION