REQUEST FOR LICENSE CERTIFICATION

Please complete this form in its entirety. Incomplete forms will be rejected.

This application is a request to send your licensing and educational information to another state. This is NOT an application to renew your license in West Virginia. To renew your license online, go to www.wvbbc.com and click on "Individual License Renewal."

Requirement for Processing Include:
$35.00 processing fee
Completed Application

YOUR INFORMATION
SSN:		License Number:

Name:

License Number:

Address:

City:

State:

Zip Code:

County:

Phone:

STATE BOARD THAT WILL RECEIVE YOUR INFORMATION

State Board Name:	*		Board Phone:	*
Board Address:	*
Board City:	*	State:	Zip Code:	*
Boards Email: