NATIONAL CERTIFIED GUARDIAN APPLICATION FOR RE-CERTIFICATION
$150.00 Re-Certification Application Fee $185.00 Re-Certification Application Fee with $35 Late Fee $35.00 Late Fee
Full Name
(as you wish it to appear on your certificate)
Date Certified
Last Four Digits of Credit Card You Are Using to Pay
Business/Firm Name:
Mailing Address:
City: State: Zip:
Work Telephone:
Fax Number:
Home Telephone:
Email Address:
List your experience providing guardianship or other alternative protective services of person or estate for
the last two years, beginning with the most recent. (optional)
Employer Name/Address
Position
Start and end dates
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
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 National Certified Guardian Re-certification Application.
Complete, sign and fax the National Certified Guardian Declaration and Agreement and the Documentation for Re-Certification Form. Also fax a listing of the dates, courses taken, program sponsors, locations, and the number of hours completed for
each course in the last two years. Re-certification requires attendance/participation in at least 20 hours of continuing
education and guardianship training every two years. Please complete the attached Documentation for Re-Certification
Form and return with this application.
Fax to 717-238-9985.
