California Certification and National NCG Certification

Full Name (as you wish it to appear on your certificate)

Last Four Digits of Credit Card You Are Using to Pay

Exam Eligibility Number from the Professional Fiduciaries Bureau

Business/Firm Name:

Mailing Address:

City: State: Zip:

Work Telephone:  Fax Number:

Home Telephone:  Email Address:

Have you ever been convicted or pled guilty or no contest to a felony? Yes No Have you ever been found civilly liable for an action of fraud, moral turpitude, misrepresentation, material omission, misappropriation, theft, or conversion? If yes, please submit a letter of explanation, including the case number. Yes No Have you ever been relieved of responsibilities as a guardian or conservator by a court, employer, or client for actions involving fraud, misrepresentation, material omission, misappropriation, theft, or conversion? If yes, please submit a letter explaining the circumstances. Yes No Are you bonded in accordance with California Statutes and local practice? Yes No If no, please explain. Have you ever been found liable in a subrogation action by an insurance or bonding agent? Yes No If yes, please explain.

Do you have any special needs requiring CGC attention? Yes No

If yes, please explain.

Please download the California Certification Application. Complete and sign the National Certified Guardian Declaration and Agreement. Fax to 717-238-9985. California Certification Application Your application is not complete until this is done.