PSA - New Board Member Application

The Charter School Office at Grand Valley State University appreciates your interest to serve as a Public School Academy Board Member.

If you are approved to serve on an Academy Board, your role is to set policy, maintain the school's vision and/or mission, promote educational excellence through advocacy, visionary leadership, and high quality services to Grand Valley State University authorized public schools as well as to ensure that the school complies with its charter and applicable law.

All Academy board members are expected by GVSU to participate in board training offered by the university. Upon approval by the GVSU Board of Trustees, a board packet will be given to each newly appointed board member.

Academy board members are public officials appointed by the GVSU Board of Trustees. All potential GVSU School Board members are required to complete this application fully.

The GVSU Board of Trustees requires each Public School Academy Board nominee to undergo a personal background check. Applications will not be processed, nor will a name be submitted to the GVSU Board of Trustees, without the results from the personal background check.


*  Denotes A Required Field

Personal Information

Academy Name:*

Your Name:*





Your Address:*




Employer Address:*


Spouse's/Partner's Name:



Are you a United States citizen?*

Are you a Michigan Resident?*


Education History

(Please indicate all of the following that apply: High School including City, State and Graduation month and year; Undergraduate institutions including the type of degree such as B.A., B.S., etc., Graduation month and year, and Major/Minor; and Postgraduate and Professional institutions again including the type of degree such as J.D., M.A., M.S., M.B.A., Ph.D., etc., Graduation month and year, and the area of concentration)


High School






Undergraduate Institutions (B.A.; B.S.; B.B.A.; etc.)

Institution 1   *


Institution 2   


Institution 3   



Post-Graduate and Professional Institutions (M.A.; M.S.; M.B.A.; M.Ed.; Ph.D., J.D., M.D., etc.)

Institution 1   


Institution 2   


Institution 3   


Employment Experience

Please list your employment experience for the past 10 years























Resume

Upload Resume:        

Please upload your resume as a .pdf or .doc/.docx file (optional)

Additional Qualifications

Conflicts of Interest

If you answer "yes" to any of the following questions, please provide an explanation

Do you know of any person or group who might take overt or covert steps to attack, even unfairly, your appointment? If yes, please identify and explain the basis for the potential.*

Do you or your spouse/partner have any contractual agreements with the Academy?*

Do you or your spouse/partner have any ownership interest in any management company contracting with the Academy?*

Have you or your spouse/partner guaranteed any loans for the Academy?*

Will your or your spouse/partner be leasing or selling any real property to the Academy?*

Will you or your spouse/partner be employed at the Academy (either as an employee of the Academy or as an employee of a management company contracted by the Academy)?*

Do you or your spouse/partner sell any supplies, materials, equipment or other personal property to the Academy?*

Have you or your spouse/partner provided any start-up funds to the Academy? If so, how much?*

Do you or your spouse/partner, or other close family members have ownership, interest, whether directly or indirectly, in any corporation, partnership, association, or other legal entity which will enter into a contract with the Academy?*

Do you currently serve as a public official?*

Is there any other matter in which you are involved which is or may be incompatible or in conflict with the discharge of the duties of the position to which you seek to be appointed or which may impair or tend to impair your independence of judgment or action in the performance of the duties of that position?*

Ethical Matters

Citations
Have you ever been cited for a breach of ethics for unprofessional conduct by, or been named in, a complaint to any court, administrative agency, professional association, disciplinary committee, or other professional group?*

Convictions
Have you ever been convicted of or entered a plea of guilty or nolo contendre or forfeited collateral for any criminal violation other than a minor traffic offense? (Minor traffic offenses do not include the Michigan offenses of operating under the influence of liquor, operating while impaired, reckless driving, or the equivalent offenses in other states.)*

Current Charges
Are you now under charges for any violation of law?*

U.S. Military Convictions
Have you ever been convicted by any military court?*

Imprisonment
Have you ever been imprisoned, been on probation, or been on parole?*

Agency Proceedings: Civil Litigation
Are you presently, or have you ever been a party in interest in any administrative agency proceedings or civil litigation which is related in any way to the position to which you seek to be appointed?*

Agency Proceedings and Civil Litigation of Affiliates and Family
Has any business in which you, your spouse/partner, close family members or business associate are or were an officer, director, or partner been a party to any administrative agency proceedings or civil litigation relevant to the position to which you seek to be appointed? (With respect to this question, you need only consider proceedings and litigation that occurred while you, your spouse/partner, close family member or business associate were an officer of that business.)*

Other
Is there any other any additional information, favorable or unfavorable, which you feel should be considered in connection with your appointment?*

References

Please submit three (3) character references. References must have no familial relation to you, i.e. no blood relatives or relatives by marriage.

Reference 1*

   (xxx - xxx - xxxx)

Reference 2*

   (xxx - xxx - xxxx)

Reference 3*

   (xxx - xxx - xxxx)

Application Verification

I recognize that all information submitted with this application or gathered by Grand Valley State University 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 Grand Valley State University, its trustees, officers, employees 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.

  By checking this box I agree to the above terms and certify that the information provided in this statement is, to the best of my knowledge, true and accurate.

Please Note: Public School Academy Board Applications are subject to public disclosure under the Michigan Freedom of Information Act.

Personal Background Check Consent

A criminal records check must be conducted as a condition for appointment as a public official serving on the board of a public school academy authorized by Grand Valley State University. This consent does not authorize nor will Grand Valley State University conduct a consumer credit check.

Information requested on this page will be used to conduct a criminal records check and will not be used to determine qualifications as a proposed public school academy board member. This page will be removed prior to review of the information contained in the application.

Additional Information Needed for Background Check


Most Recent Former Address:*

Gender:*

Caucasian African American
Hispanic Asian
Native American Other

  By checking this box I agree to the above terms and assert and certify that the information provided is, to the best of my knowledge, true and complete.

In accordance with SB 618 (PA 277 of 2011), all board members of GVSU authorized academies must be US citizens and Michigan residents. Moving forward, new board members will be asked to bring the following items to their initial interview with a GVSU Field Service Representative: One (1) document proving US citizenship; Two (2) documents proving Michigan residency.

List of qualifying documents:

Proof of US citizenship (pick one):

  • Certified birth certificate with a raised seal issued by a US or US territory government office
  • Valid, unexpired US passport or passport card
  • Certified Certificate of Citizenship (N-560 or N-561)
  • Certified Certificate of Naturalization (N-550, N-570, or N-578)
  • Consular Report of Birth Abroad issued by the US Department of State (FS-240, DS-1350, or FS-545)


Proof of Michigan residency (pick two):

  • Utility bill or credit card bill issued within the last 90 days (electronic copies are acceptable)
  • Account statement from a bank or other financial institution issued within the last 90 days (E-copies are acceptable)
  • Mortgage, lease, or rental agreement
  • Pay stub or earnings statement issued with the name and address of employer
  • Life, health, auto, or home insurance policy
  • Federal, state, or local government documents, such as receipts, licenses, or assessments
  • Michigan title and registration (The registration must show current residential address)


By submitting this document I acknowledge receipt of this disclosure and authorize Grand Valley State University to obtain a copy of my criminal records report.

I consent to the release of information concerning my criminal record, subject to any restrictions that I have included, to Grand Valley State University, its Charter Schools Office and its legal counsel. I specifically authorize Grand Valley State University to conduct a criminal records check on me with the applicable local, state and federal law enforcement agencies.

I will hold Grand Valley State University, its trustees, officers, employees or authorized agents harmless from liability for the disclosure of any information it reasonable believes is true based upon my representations or resulting from this criminal records check consent process.

  By checking this box I agree to the above terms and assert and certify that the information provided is, to the best of my knowledge, true and complete.