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.Format: (000) 000-0000.
Member email address
example@example.com
What type of change do you need to make? Please select one.
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.Format: (000) 000-0000.
New email address
example@example.com
New work title
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.Format: (000) 000-0000.
New membership dues payment method type
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?
What other type of change do you need to make? Please select one.
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.Format: (000) 000-0000.
New email address
example@example.com
New work title
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.Format: (000) 000-0000.
New membership dues payment method type
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