Last Four Digits of Credit Card You Are Using to Pay
Exam Date:
Exam Location:
2. Business/Firm Name:
3. Mailing Address:
City: State: Zip:
4. Work Telephone:
Fax Number:
5. Home Telephone:
Email Address:
6. Applicants should have at least one year of work experience in guardianship or a related field. List your experience over the past two years providing guardianship of person or estate, or other related work experience, beginning with the most recent activities.
Employer Name/Address
Position
Start and end dates
7. Applicants without qualifying work experience may also become eligible through education or training.
Education Graduate Degree:
Concentration:
Year Awarded:
College/University:
City/State:
Bachelors Degree:
Major:
Year Awarded:
College/University:
City/State:
Nursing Degree:
Year Awarded:
School:
City/State:
Training:
Please attach a listing of the dates, courses taken, program sponsors, locations, and number of hours
completed for each course in the past two years.
8. Have you ever been convicted or pled guilty or no contest to a felony?
Yes
No
9. Have you ever been found civilly liable for an action of fraud, moral turpitude, misrepresentation, material
omission, misappropriation, theft, or conversion?
Yes
No
If yes, please explain, including the case number.
10. 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?
Yes
No
If yes, please explain the circumstances.
11. Are you bonded in accordance with state statutes and local practice?
Yes
No
If no, please explain.
12. Have you ever been found liable in a subrogation action by an insurance or bonding agent?
Yes
No
If yes, please explain. (Please refer to your local state courts)
13. Do you have any special needs requiring CGC attention?
Yes
No
If yes, please explain.
Please download the forms located on the following link. Complete, sign and fax the signature page and Declaration and Agreement to 717-238-9985.
