Change Report For Provisional License Form


Provisional Licensees who change employers, DHHR county offices, titles, and/or licensing supervisors must file a Change  for Provisional License Form with the Board.


To file a Change Report for Provisional License:

Download, complete, and return the form listed below.

Get Adobe ReaderChange Report for Provisional License Form (PDF)


Completed applications must be mailed to the Board office:

WV Board of Social Work
PO Box 5459
Charleston, WV 25361

Fax #: 304-400-4976