Policy LBD-E Intent to Apply to Become a District Charter School

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:

  1. 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): _______________________________________________

  1. 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): ____________________________

  1. 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): ___________________________

  1. 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