Replacement Certificate or Card
Use this form to request a replacement certificate or card.
Name
*
First Name
Last Name
Is this a name change?
Yes, and I have completed the demographics form.
No
Yes, and I plan to fill out the demographic form next.
Demographic Change Form Link:
https://form.jotform.com/250314777820154
Former Name if this is a name change:
First Name
Last Name
If this is a name change, upload new ID and supporting legal documents showing the name change. You will need to fill out a demographics change form as well.
Browse Files
Drag and drop files here
Choose a file
ID, marriage certificate, divorce decree, etc.
Cancel
of
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Certificate Number
Which credential's certificate do you need replaced?
*
AADC, ADC, PRSS-MH/SUD etc.
What do you need replaced?
*
Wallet Card
Certificate(s)
Both wallet card and certificate(s)
How will you be paying the replacement fee?
*
Please Select
PayPal using this form
PayPal using the WVCBAPP website
Mail Check Allow 3 weeks for processing
Mail Money Order Allow 3 weeks for processing
Certificate or Card Replacement Fee
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( X )
Certificate/Card Replacement Fee
Pay here via PayPal with an 8% fee or mail a check or money order to WVCBAPP for 20.00
$
21.60
Name or agency on the PayPal account
Signature
*
Date
*
-
Month
-
Day
Year
Date
Continue
Continue
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