Post Office Box 638
1715 Flat Top Road
CoolRidge, WV 25825
Phone: (304) 787-4398 Toll Free: (877) 609-9869 Fax: (304) 787-3030
Email: wvrtboe@suddenlinkmail.com
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Change of Address or Employer

THIS FORM CANNOT BE USED FOR A CHANGE OF NAME.

IT IS THE LICENSEE'S RESPONSIBILITY TO ENSURE THE OFFICE HAS YOUR CORRECT ADDRESS. PLEASE COMPLETE THIS FORM FOR ANY CHANGE OF YOUR ADDRESS OR YOUR EMPLOYER INFORMATION.

REQUESTED INFORMATION MARKED WITH AN * IS MANDATORY INFORMATION.

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