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    A Commitment to Excellence in Education

     

    Thank you for your willingness to serve as a public school academy board member.  The boards of these schools play a vital role in their future.  If you are appointed to serve on an academy board, your role will be to set policy, maintain the school’s vision, and ensure that the school complies with its charter and applicable law.

     

    We have designed this application to be straightforward, while collecting the detailed information needed to appoint effective board members.

     

     

    Please forward application to:

    The Field Officer for your Academ

     

     LSSU Charter School Field Officers

     

    Glenn Bachman, grbachman1@gmail.com

              American International Academy

              Detroit Service Learning

              Momentum Academy

              Tipton Academy

              W-A-Y Academy

              WAY-Flint Academy

     

    Larry Kubovchick, lkubovchick@lssu.edu

              Bay City Academy

              Charlton Heston Academy

              Concord Academy – Boyne

              Concord Academy of Petoskey

              DeTour Arts & Technology Academy

              Grand Traverse Academy

     

    Larry Lindquist, llindquist@charter.net

              Grand Rapids Ellington Academy of Arts & Tech

              iCademy

              Innocademy

              Innocademy Allegan Campus

              Innocademy Pyramid Campus

              Ridge Park Charter Academy

     

    Pat Victor, pmvictor@att.net

              Advanced Technology Academy

              Macomb Montessori Academy

              Regent Park Scholars Academy

              Webber Media Arts Academy

              WSC Academy

     

     

     

                 

    Application for Appointment to the Board of a Public School Academy

     

    I hereby request appointment to the board of the following public school academy:

     

    Name of Academy:______________________City________________

     

    Personal Information

     

    Full Name (include middle name):  ___________________________________________

     

    Home Address: __________________________________________________________

                                        Street/P.O                               City, State, Zip

     

    Email Address: __________________________________________________________

     

    Social Security Number: _________________Date of Birth______________________

     

    Employer’s Name: _______________________________________________________

     

    Employer’s Address: _____________________________________________________

     

    County: ________________Position: ________________________________________

     

    Home Telephone: ___________________ Fax: ________________________________

     

    Work Telephone: ___________________ Cell Phone: __________________________

     

    Spouse’s Full Name: 


    Do your children attend this academy?                  If so, list their ages:

     

    Please check (ü) your highest education level:

    High School/GED ______Associate’s Degree ______BA or BS Degree

    ______Master’s Degree _______Doctoral or Professional Degree

    ______Trade/Business School _______Other __________

     


    Please check each area of expertise you would contribute to the Board:

                Community Service                            Education                                Finance

    Fund Raising                                       Law                                        Management

                Marketing                                            Human Resources

    _____ Public Relations                       _____Parental Involvement Programs

    _____ Others (please specify): ______________________________

     

    Will you be able to attend regularly scheduled Board meetings?  Yes     or     No

    Public School Academy Board Qualifications Guide

     

    Instructions:  Use a separate sheet of paper to explain your experience in the following categories.

    §  Government. Experience in local, state or federal governmental agencies and departments, including advisory, consultative, honorary or other service or positions. Include dates of services.

    §  Elected Public Office. Include dates of service.

    §  Honors and Awards.  Include scholarships, fellowships, honorary degrees, honorary society memberships and recognition for outstanding service or achievements.

    §  Employment Experience. Include job and career information

    §  Professional Licenses and Certifications.  List complete titles and license numbers.

    §  Volunteer Experience. Include work done and leadership positions.

    §  Miscellaneous.  Explain any additional points, including special skills that qualify you for the position.

    §  References.  If you are applying for your first term as a member of this board, list three individuals who would be willing to talk with Lake Superior State University regarding your qualifications. Include their names, addresses, business and home telephone numbers and their relationship to you.

     

     

    Relationship to the Public School Academy

     

    Instructions:  If you answer “yes” to any of the following questions, please provide an explanation on a separate sheet of paper. Please label explanations with the number of the corresponding question.

     

    1.      Do or will you or your spouse have any contractual agreements with the academy?      Yes   or    No

     

    2.      Do or will you, your spouse, or any member of your immediate family have any ownership interest in any management company or any other company contracting with the academy?      Yes   or   No

     

    3.      Did or will you or your spouse lease or sell property to the academy?      Yes   or   No

     

    4.      Did or will you or your spouse sell any supplies, materials, equipment or other personal property to the academy?        Yes   or   No

     

    5.      Have you or your spouse guaranteed any loans for the academy or loaned it money?    Yes   or   No

     

    6.      Are or will you, your spouse or any member of your immediate family or household be employed by the academy, its management company or its other service providers?          Yes    or     No

     

    7.      Did you or your spouse provide any start-up funds to the academy?      Yes    or     No

     

    8.      Did or do you or your spouse, or other member of your immediate family, have ownership interest, directly or indirectly, in any corporation, partnership, association or other legal entity which would answer “yes” to any of the questions 1 – 7?

    Yes    or      No

     

    9.      Does any other board, group or corporation believe it has a right to control or have input into votes you will cast as a member of the public school academy board?        Yes   or   No

     

    10.  Do you currently serve as a member of the board of any public school district or public school academy?       Yes       or         No

     

    11.  Do you currently serve as a public official?                                  Yes      or         No

     

    12.  To the best of your knowledge, are there situations not described above which may give the appearance of a conflict of interest between you and the academy, or which would make it difficult for you to discharge your duties or exercise your judgment independently on behalf of the academy?    Yes   or    No

     


    Ethical Issues

     

    Instructions:   If you answer “yes” to either of the following questions, please provide an explanation on a separate sheet of paper.

     

       Citations.

     

                Have you ever been cited for a breach of ethics for unprofessional conduct or been named in a complaint to a court, administrative agency, professional association, disciplinary committee or other professional group?            Yes   or   No

     

       Agency Proceedings/Civil Litigation.

     

                Are you presently or have you ever been involved in administrative agency proceedings or civil litigation during the past five years?                  Yes    or    No

     

                Has any business involving you, your spouse, close family member or close business associates been part of any administrative agency proceedings or civil litigation relevant to the board member position?               Yes     or      No

     

     

    Criminal Background Check

     

    Public School Academy Board members are public officials appointed by the Lake Superior State University Board of Trustees. The University Board requires that a personal background check, including a criminal record verification, for each nominee.

     

    Instructions:  Complete this section by placing your initials in the space beside option 1, 2 and/or 3. If you initial option 2 or 3, please provide the requested details.

     

    1. I have not been convicted of, nor pled guilty or nolo contendere (no contest) to any crimes.

     

    2   I currently am charged with one or more crimes.

    (On a separate sheet of paper, specify what the charges are and which courts are involved.)

     

    3.  I have been convicted of or pled guilty or nolo contendere to one or more crimes.

    (On a separate sheet of paper, specify what the charges were and which courts were involved.)

     


    I understand that:

       Lake Superior State University must request or cause a criminal records check on me from local, state, or federal law enforcement agencies.  Until that report is received and reviewed by Lake Superior State University, my nomination for appointment will not be processed.If the report received from the local, state, or federal law enforcement agencies is not the same as my representation(s) above or attached hereto respecting the absence of any conviction(s) or any crimes of which I have been convicted, my nomination for appointment is voided at the sole discretion of the Lake Superior State University Board of Trustees or its designee.

     

                                                                Signature                                                         Date

     

     

    Public School Academy Board Application Verification and Consent

     

     

    My signature below verifies that all information provided in this application is true and complete.

     

    I consent to the release of information concerning my ability and fitness by my employer(s), schools, law enforcement agencies and any other individuals and organizations, subject to any restrictions that I have included, to Lake Superior State University, its Provost’s Office and the University’s legal counsel. I specifically authorize LSSU to do a criminal background check on me with the applicable local, state and federal law enforcement agencies.

     

    I recognize that all information submitted with this application or gathered by LSSU as a result of this application becomes a matter of public record, subject by law to disclosure upon request to members of the general public. I will hold LSSU, it Board of Trustees, officers, employee or authorized agents harmless from liability for the disclosure of any information it reasonably believes is true based upon my representations or resulting from this application process.

     

    I understand that Lake Superior State University is under no obligation to appoint me or any nominee to the public school academy board.

     

    I am a citizen of the United States of America.

     

     

     

     

                           

                            Signature                                                                                 Date               

    Lake Superior State University

    Charter School Office

    Verification of U.S. Citizenship

    PSA Board Member

     

    Name of Academy________________________________________________________

     

    Name of Board Member____________________________________________________

                                                                Last                         First                         Middle Initial           (Maiden)

     

    Address           __________________________________________________________________

                                        Street Name and Number

               

                            __________________________________________________________________

                                        City                                                                         State        Zip Code

     

    I attest that I am a citizen of the United States of America and a resident of the State of Michigan.

     

     

                Board Member’s Signature

     

     

    Charter School Office Verification

     

    I have examined the __________________________________presented by the above

                                                    Name of document

    named board member.  The document appears to be genuine and to relate to the person named and to the best of my knowledge the person is a U.S. citizen and resident of the State of Michigan.

     

     

     

                Signed, Name, Title                 LSSU Charter School Office

     

     

    Acceptable documents as proof of citizenship include the following:

    ·         Original or certified copy of birth certificate issued by a State, county, municipal authority or territory of the United States bearing an official seal.

    ·         Native American tribal document

    ·         U.S. Citizen ID Card (Form I-197)

    ·         Michigan Enhanced Driver License

    ·         U.S. Passport or U.S. Passport Card

     

    A Commitment to Excellence in Education

     

    Thank you for your willingness to serve as a public school academy board member.  The boards of these schools play a vital role in their future.  If you are appointed to serve on an academy board, your role will be to set policy, maintain the school’s vision, and ensure that the school complies with its charter and applicable law.

     

    We have designed this application to be straightforward, while collecting the detailed information needed to appoint effective board members.