Application for Certification as a National Master Guardian

$150.00 Non-Refundable Application fee and a $375.00 Exam Fee

$100.00 Re-Testing Fee
(only applicable if previous examination was not passed successfully)
$35.00 Late Cancellation Fee

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

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:

Telephone (Where You Wish To Be Contacted):

Fax Number:

Email Address:

Q1. Have you ever been convicted or pled guilty or no contest to a felony? (CGC will be verifying this information through a criminal background check. Details will be provided in a separate e-mail.)

Yes
No

Q2. 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

Q3. 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

Q4. Are you bonded in accordance with state statutes and local practice?

Yes
No

Q5. 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)

Q6. Do you have any special needs requiring CGC attention?

Yes
No

If yes, please explain.

Education
- This information will be verified through a third-party vendor. Be sure you are accurate with the information you are submitting

Graduate Degree
Concentration:		Year Awarded:
College/University:		City/State:
Upload proof of education(transcripts/diplomas/etc.):

Bachelors Degree
Major:		Year Awarded:
College/University:		City/State:
Upload proof of education(transcripts/diplomas/etc.):

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:

Resume

Please upload your resume here:

Proof of Current Employment/Experience

Please send one of the affidavits listed on the homepage of the NMG application (depending upon how you obtained your experience) to a current or previous employer. They must complete the form provided and return it directly to CGC. You may not return it on their behalf.

Proof of Continuing Education Units

Program Sponsor	Date	Location	Hours	Attach Certificate

Licensure and Certificates

1. Have you ever been issued a license or professional certificate (other than NCG/MCG) in any state?		Yes No
Type:	Governing Board/State:
Certificate Nbr:	Date Issued:
2. Have you ever had a license or professional certificate revoked, suspended, or subject to other discipline?			Yes No
If yes, please explain.

Narrative

To apply for NMG status, you must provide a narrative to CGC. The narrative should be typed in any word processing program or in PDF format, then uploaded to this application by browsing for the file below. The specifics about the narrative are as follows:

Narrative of how your experience qualifies you as a National Master Guardian. Your narrative should specifically address your experience relative to "1" below and at least five (5) additional indicators from the following list:

Attach Narrative: