File: LBD*-E
Intent to Apply to Become a District Charter School
(Sample Form)
Instructions: All district charter school applicants must file this intent to apply form with the district at least ________ days before submitting an application to the Board of Education. The intent to apply form may be returned by fax to _____________ or email to ___________________________________. The form should also be the first document included in the district charter school application.
Date: ___________________
Name of proposed district charter school: ________________________________
Name of education management provider (EMP), if applicable: __________________________________
Contact person: ____________________________________________________
Mailing address: ____________________________________________________
City: ______________________________ State: _______ Zip: ______________
Daytime phone: _______________________ Fax: _________________________
Email: ____________________________________________________________
___________________________________________________________________
Please respond to the following:
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Applicant(s) has/will file an application to charter this school or a substantially similar school with other authorizers: ? Yes ? No If yes, please list the other authorizer(s): _______________________________________________
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Applicant(s) submitting this form: (Check appropriate statement)
? is incorporated in Colorado as a nonprofit
? has filed application to become a Colorado nonprofit
? (state type of entity, if other than above): ____________________________
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If applicant intends to contract with an EMP, the corporate status of the EMP is:
? incorporated in Colorado as a nonprofit
? has filed application to become a Colorado nonprofit
? (state type of entity, if other than above): ___________________________
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The proposed district charter school will be located within the boundaries of the school district in which this intent to apply form is submitted: ? Yes ? No, the proposed district charter school will be located in __________________.
Issued: September 23, 2014
Huerfano School District Re-1, Walsenburg, Colorado