All OTA's working in WV are required to keep a current, signed Supervisory Statement on file with the Board. Please print the form below. Complete, 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, faxed to 304-285-3150, or mailed to the address shown on the form.
A new signed Supervisory Statement is also required as part of license renewal requirements.