Academy Name:*
Choose your academy... Academy not listed Achieve Charter Academy Arbor Academy Black River Public School Byron Center Charter School Canton Preparatory High School Chandler Woods Charter Academy Cornerstone-Jefferson Douglass Academy Covenant High School Grand Rapids Covenant Schools Detroit Crossroads Charter Academy Detroit Achievement Academy Detroit Enterprise Academy Detroit Merit Charter Academy Detroit Premier Academy Eagles Nest Academy East Arbor Charter Academy Endeavor Charter Academy Excel Charter Academy Flint Cultural Center Academy Fostering Leadership Academy GEE Compass Academy Gerald Dawkins Academy Global Heights Academy Grand River Academy Grand River Preparatory High School Hanley International Academy Hillsdale Preparatory School Kalamazoo Covenant Academy Knapp Charter Academy Legacy Charter Academy Light of the World Academy Lincoln-King Adams-Young Academy Madison-Carver Academy Martin Luther King Jr. Education Center Academy Metro Charter Academy Michigan Mathematics and Science Academy Muskegon Covenant Academy New Paradigm College Prep New Paradigm Glazer-Loving Academy Oakland Academy Old Mission Peninsula School PSAD Paragon Charter Academy PrepNet Virtual Academy Reach Charter Academy Saginaw Covenant Academy South Canton Scholars Charter Academy Taylor Preparatory High School The Greenspire School Timberland Charter Academy Vanderbilt Charter Academy Vanguard Charter Academy Walker Charter Academy Warrendale Charter Academy Washington-Parks Academy West Michigan Academy of Arts and Academics West Michigan Aviation Academy Westfield Charter Academy William C. Abney Academy Windemere Park Charter Academy

Your Name

Title:

First: *

Middle:

Last: *

Suffix:

Email Address: *

Your Address

Street: *

County: *

City: *

State: *
- Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming

Zipcode: *

Home Phone Number: *

Employer: *

Position/Job Title: *

Employer Address

Street: *

County: *

City: *

State: *
- Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming

Zipcode: *

Work Phone Number: *

Spouse's/Partner's Name

First:

Middle:

Last:

Suffix:

Are you a United States citizen? *
Yes No

Are you a Michigan Resident? *
Yes No

Are you the parent/guardian of a current or former student at the academy you are applying to for board membership? *
Yes No

(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

High School: *

City/State: *

Graduation Date (Month/Year): *

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

Institution 1: *
Choose Degree Type... B.A. B.S. B.B.A. B.F.A. Other Not Applicable

Degree Type: *

Institution 2:
Choose Degree Type... B.A. B.S. B.B.A. B.F.A. Other Not Applicable

Degree Type:

Institution 3:
Choose Degree Type... B.A. B.S. B.B.A. B.F.A. Other Not Applicable

Degree Type:

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

Institution 1:
Choose Degree Type... M.A. M.S. M.B.A M.Ed. Ph.D. J.D. M.D. Other Not Applicable

Degree Type:

Institution 2: Choose Degree Type... M.A. M.S. M.B.A M.Ed. Ph.D. J.D. M.D. Other Not Applicable

Degree Type:

Institution 3:
Choose Degree Type... M.A. M.S. M.B.A M.Ed. Ph.D. J.D. M.D. Other Not Applicable

Degree Type:

Please list your employment experience for the past 10 years

Employer 1: *

Dates of Employment (Month/Year - Month/Year): *

Job Title: *

Employer 2:

Dates of Employment (Month/Year - Month/Year):

Job Title:

Employer 3:

Dates of Employment (Month/Year - Month/Year):

Job Title:

Employer 4:

Dates of Employment (Month/Year - Month/Year):

Job Title:

Do you hold any professional licenses? If so, please describe the licenses including the license numbers

What special skills could you bring to the public school academy board? *

Previous government appointments? (if any)

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

Government Experiences *
List any experience in, or association with, local, state or federal government (exclusive of elective public office but including advisory, consultative, honorary, or other part-time service or position), with dates of service.

Elective Public Office *
List all elective public offices sought and held with dates of service.

Honors and Awards *
List all scholarships, fellowships, honorary degrees, honorary society memberships, and any other special recognition for outstanding service or achievement.

Volunteer Experiences *
List all experience with volunteer organizations and positions held.

Miscellaneous *
List any additional points, including special skills that qualify you for this position.

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. *
Yes
No

Please Explain:

Do you or your spouse/partner have any contractual agreements with the Academy? *
Yes
No

Please Explain:

Do you or your spouse/partner have any ownership interest in any management company contracting with the Academy? *
Yes
No

Please Explain:

Have you or your spouse/partner guaranteed any loans for the Academy? *
Yes
No

Please Explain:

Will your or your spouse/partner be leasing or selling any real property to the Academy? *
Yes
No

Please Explain:

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)? *
Yes
No

Please Explain:

Do you or your spouse/partner sell any supplies, materials, equipment or other personal property to the Academy? *
Yes
No

Please Explain:

Have you or your spouse/partner provided any start-up funds to the Academy? If so, how much?*
Yes
No

Please Explain:

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? *
Yes
No

Please Explain:

Do you currently serve as a public official? *
Yes
No

Please Explain:

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? *
Yes
No

Please Explain:

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? *
Yes
No

Please Explain:

Convictions
Have you ever been convicted of or entered a plea of guilty or nolo contendre or forfeited collateral for any criminal violation, including operating under the influence of liquor, operating while impaired, reckless driving, or the equivalent of in other states? *
Yes
No

Please Explain:

Current Charges
Are you now under charges for any violation of law? *
Yes
No

Please Explain:

U.S. Military Convictions
Have you ever been convicted by any military court? *
Yes
No

Please Explain:

Imprisonment
Have you ever been imprisoned, been on probation, or been on parole? *
Yes
No

Please Explain:

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? *
Yes
No

Please Explain:

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.) *
Yes
No

Please Explain:

Other
Is there any other any additional information, favorable or unfavorable, which you feel should be considered in connection with your appointment? *
Yes
No

Please Explain:

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 *

Name:

Relationship to you:

Phone Number:

How long have you known this person?

Reference 2 *

Name:

Relationship to you:

Phone Number:

How long have you known this person?

Reference 3 *

Name:

Relationship to you:

Phone Number:

How long have you known this person?

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.

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

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

Date Of Birth: *
Month: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year: 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024

Maiden Names:

Any Previously Used Names?

Most Recent Former Address

Street: *

City: *

State: *
- Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming

Zipcode: *

Gender: *
Male Female

Ethnicity: *
Caucasian
African American
Hispanic
Asian
Native American
Other
Please specify:

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.