Last Four Digits of Credit Card You Are Using to Pay
Date Certified as a National Certified Guardian
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 state statutes and local practice?
Yes
No
Have you ever been found liable in a subrogation action by an insurance or bonding agent?
Yes
No
If no, please explain. (Please refer to your local state courts)
Do you have any special needs requiring CGC attention? Yes No
If yes, please explain.
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:
List four (4) individuals who can provide a letter of recommendation relevant to your professional guardianship practice:
Name:
Address:
Phone:
Fax:
Email:
Name:
Address:
Phone:
Fax:
Email:
Name:
Address:
Phone:
Fax:
Email:
Name:
Address:
Phone:
Fax:
Email:
Please download the National Master Guardian Application. Follow the directions to complete the narrative. Fax the narrative, Four (4) professional letters of recommendation on the approved CGC recommendation form, Confidentiality waiver and Proof of employment and education to 717-238-9985.
