Oregon Certification and National NCG Certification

All fields must be completed or the application cannot be submitted.

Fees

$275.00 Non-refundable Application and exam fee for Oregon Certification and National NCG Certification
$175.00 Non-refundable Application and exam fee for Oregon Certification (only if applicant already possesses NCG Certification)
$100.00 Non-refundable Re-examination 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
Business/Firm Name:
Mailing Address:
City:
State:
Zip:
Telephone:
Fax Number:
Email Address:
For details regarding employment, education and experience requirements for Oregon applicants, please click on this document for details.

Work Experience

Employer Name/Address Position Start and end dates

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
Include a listing of the dates, courses taken, program sponsors, locations, and number of hours completed for each course in the past two years.

Upload training document

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.
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 Oregon Statutes and local practice? Yes
No
If no, please explain.
Q5. Have you ever been found liable in a subrogation action by an insurance or bonding agent? Yes
No
If yes, please explain.
Q6. Do you have any special needs requiring CGC attention? Yes
No
If yes, please explain.