All OTA's working in WV are required to keep a current, signed Supervisory Statement on file with the Board. Please complete the form below, sign, and obtain signatures from all supervising OTR's. One form should be completed for each facility. Completed forms can be emailed to wvbot@wv.gov or mailed to the address shown on the form.
A new signed Supervisory Statement is also required as part of license renewal requirements and can be uploaded as part of the renewal application.