Renewal Application for GBOE

RENEWAL APPLICATION

for CC&T & Pastoral Counselors
Board Certification Type:

Christian Counselor and Therapist Pastoral Counselor
PERSONAL INFORMATION
Enter your name exactly as you want it to appear on your membership card
First Name
Middle Name
Last Name
Degree
Street Address
City
State
State Abbreviation
Zip Code
E-mail Address
example@example.com
Telephone Number (Home)
Date of birth

Month Day Year
Date
Last 4 digits of social security number
Have you ever served active duty in the Armed Forces, the Reserves, or the National Guard during wartime or during any conflict when military personnel were commissioned by the President?

Yes No
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OATH
I acknowledge that I may be required to furnish additional information
promptly in order for this application to be processed. I attest that the
information provided is true and accurate to the best of my knowledge. I
attest that I am a resident of the State of Georgia, or that I intend to be
within one year of the date of this application. I release from all harm the
Board of Examiners for Christian Counselors and Therapists and authorize
them to investigate and gather all information relevant to my application
for Board Certification. I have read, understand and agree to abide by the
Code of Ethics as set forth by the Board of Examiners for Georgia Christian
Counselors and Therapists.
As representatives of Jesus Christ, you are responsible to demonstrate a
lifestyle consistent with His character and are expected to be men and
women of high moral character and whose sexual conduct is consistent with
the standards of Scripture. This includes abstaining from any pattern of
addiction and from homosexual, premarital, and extramarital sexual
conduct.
Signature

Clear
Date

Month Day Year
Date
Click the link below to submit your application. You will then see a link to pay your renewal fees. (Right-click the link and select open in a new tab)

Note: your renewal will not be processed until you have paid.

The fees are as follows: $200 (2 years and LGN Association) for each certification. (non-refundable)

Providing incorrect or partially incomplete applications will cause a delay until the problems are corrected.
Should be Empty:

RENEWAL APPLICATION

PERSONAL INFORMATION

OATH