NCGA - Re-Certification (Online version)

Re-Certification

	Full Name
	Are you a NCGA member?
	Business/Agency Name (if applicable)
	Mailing Address
	City
	State
	Zip Code:
	Daytime Telephone Number
	Evening Telephone Number
	Fax Number
	Email Address
	List your experience providing guardianship or other alternative protective service of person or estate for the last 2 years, beginning with the most recent.
	Employer Name/Address
	Position
	Begin Date
	End Date
	Employer Name/Address
	Position
	Begin Date
	End Date
	Employer Name/Address
	Position
	Begin Date
	End Date
	Guardianship Education and Related Courses On a separate piece of paper please provide with dates, speaker bureaus or presentations, courses taken, program sponsors, locations and the number of hours completed for each course with appropriate documentation.
	Have you ever been removed for cause as guardian or fiduciary?
	If yes, attach a leter of explanation.
	Have you ever been convicted or pleaded guilty or no contest to a misdemeanor or felony?
	If yes, please indicate the offense along with the name and location of the court before which you appeared and the dispositions of the case

	Have you ever been found civilly or criminally liable for an action of fraud, misrepresentation, material omission, misappropriation, theft, or conversion?
	If yes, please explain.


*Payment will be requested after information is submitted via Paypal.