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.
Date*

MonthDayYear
Date
Name*

First NameMiddle NameLast Name
Phone Number*
Please enter a valid phone number.
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?*

Yes, I understand the cost is $20.00 and payment must be received before issued.No
If you are requesting a new/updated certificate, how will you be paying the fee?

PayPal online using this form.PayPal online using the WVCBAPP websiteMailing a check or money order to the WVCBAPP board office
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 Using PayPal has an 8% service charge added. You may mail a check or money order to WVCBAPP in the amount of $20.00.
$21.60

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*

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Date*

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Date
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