State Of West Virginia Change Notification Form
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1WVSP 44B
05/2016
STATE OF WEST VIRGINIA
CHANGE NOTIFICATION FORM
To the Sheriff of ______________________ County, I the below named individual, swear and affirm, under penalty
of law, that the information within this application is true and correct to the best of my knowledge.
Type of Permit:
Regular
Honorably Discharged LEO
Provisional
Type of change needed:
Address & County
Address only
Name
Permit status
Current Information
Permit Holder’s Name: _______________________ _________________________ _____
Last
First
MI
Address: ________________________________________________________ _____________
Street
Apt/Suite
_________________________ ________ _______________ ____________________
City
State
Zip
County
Contact: ___________________________________________
Status:
Active
Revoked
Denied
Information to be updated:
Permit Holder’s Name: _____________________ _________________________ _____
Last
First
MI
Address: ______________________________________________________ _____________
Street
Apt/Suite
_________________________ ________ _______________ ____________________
City
State
Zip
County
Status:
Revoked
Denied
Reinstated
Date of Birth _____/______/_________ Social Security Number: ______-______-_________
WV Driver’s License # _________________ WV Non-Driver’s ID# ___________________
I swear that I have not been convicted of any felony since the permit was originally issued, nor have I
been convicted of an act of Domestic Violence. I am not currently under indictment for any felony
charges or any other criminal offenses, nor am I the subject of a Domestic Violence Petition order. I
understand that falsification of any information contained within this application constitutes false
swearing and is a misdemeanor punishable under provisions of West Virginia Code 61-7-4
Applicant Signature: _________________________________________ Date: ______________
Subscribed and sworn before me, in said County and
SEAL:
State,
this
the
_________
day
of
______________________________, 20_________.
Date application received: _____/_____/_______
My commission expires: ______________________
Received by: _______________________________
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