Application - Charter School Board Member

The Division of K-12 Education Innovation and Scholar Success at GVSU appreciates your interest in serving as a public school academy board member.

Public school academy board members are public officials appointed by the GVSU Board of Trustees. All potential public school academy 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.

If you are approved to serve on an public school academy board, your role is to:

Set policies that maintain the school's vision and/or mission
Ensure that the school complies with its charter and applicable law
Promote educational excellence through advocacy, visionary leadership, and high quality services to students, educators, and families

Application Info

What type of application would you like to submit? *

Name of Public School Academy Board *

Personal Information

First Name *

Middle Name *

Last Name *

Country *

Email Address *

Email Address (Confirmation)

Phone Number *

Address Line 1 *

Address Line 2

City *

State/Province *

State/Province

Zip/Postal Code *

Are you a United States citizen? *

Are you a Michigan Resident? *

Are you the parent/guardian of a current or former student at the school? *

Education History

High School *

High School Location (City/State) *

Graduation Year *

Did you receive an undergraduate degree? *

Undergraduate Degree Type *

Name of Undergraduate Institution *

Undergraduate Major *

Undergraduate Graduation Year *

Do you have additional undergraduate degrees you'd like to add? *

Undergraduate Degree Type 2

Name of Undergraduate Institution 2

Undergraduate Major 2

Undergraduate Graduation Year 2

Undergraduate Degree Type 3

Name of Undergraduate Institution 3

Undergraduate Major 3

Undergraduate Graduation Year 3

Do you have any graduate or post-graduate degrees you'd like to add? *

Graduate / Post-Graduate Degree Type 1 *

Name of Graduate / Post-Graduate Institution 1 *

Graduate / Post-Graduate Degree Concentration 1 *

Graduate / Post-Graduate Graduation Year *

Do you have additional graduate or post-graduate degrees you'd like to add? *

Graduate / Post-Graduate Degree Type 2

Name of Graduate / Post-Graduate Institution 2

Graduate / Post-Graduate Degree Concentration 2

Graduate / Post-Graduate Graduation Year 2

Graduate / Post-Graduate Degree Type 3

Name of Graduate / Post-Graduate Institution 3

Graduate / Post-Graduate Degree Concentration 3

Graduate / Post-Graduate Graduation Year 3

Employment

Please list your employment experience for the last 10 years.

(No questions will appear here if you are applying for reappointment)

Employer 1 *

Job Title 1 *

Dates of Employment 1 (Start Year - Current or End Year) *

Employer 1 Street Address *

Employer 1 Street Address (Line 2)

Employer 1 City *

Employer 1 State/Province *

Employer 1 Zip/Postal Code *

Employer 1 Phone Number *

Employer 2

Job Title 2

Dates of Employment 2 (Start Year - Current or End Year)

Employer 3

Job Title 3

Dates of Employment 3 (Start Year - Current or End Year)

Employer 4

Job Title 4

Dates of Employment 4 (Start Year - Current or End Year)

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

Previous government appointments? (if any)

Resume

Upload Resume *
Please upload a file with the extension .doc, .docx, or .pdf with a maximum size of 10 MB.

Additional Qualifications

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. *

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

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

List all experience with volunteer organizations and positions held. *

List any additional points you'd like considered in your application for this role.

Conflicts of Interest - General

Please complete the following section by indicating yes or no. If you answer “yes” to any of the questions, please provide an explanation.

(No questions will appear here if you are applying for reappointment.)

Do you know of any person or group who might take overt or covert steps to attack, even unfairly, your appointment? *

Please explain *

Do you currently serve as a member of the board of any public school district or public school Academy other than this Academy’s board? *

Please explain *

Do you currently hold any local, state, or federal government positions, including advisory, consultative, honorary, or other part-time service or position? *

Please explain *

Do you currently serve as a public official in any capacity other than a board member for this Academy? *

Please explain *

Conflicts of Interest via Relatives

When answering Yes or No to the following questions, you must consider past, present, or future occurrences of the events detailed below involving you, your spouse/partner, mother, mother-in-law, father, father-in-law, son, son-in-law, daughter, daughter-in-law, sister, sister-in-law, brother, brother-in-law.

To the best of your knowledge, have you or any of your relatives as defined above...

(No questions will appear here if you are applying for reappointment.)

...entered into contractual agreements with the Academy or the Educational Service Provider (ESP) contracted by the Academy? *

Please Explain *

...had ownership or served in an officer, policymaking, managerial, administrative, non-clerical, or other significant role with the Academy’s ESP or employee leasing company? *

Please Explain *

...leased or sold real property to the Academy or the ESP contracted by the Academy? *

Please Explain *

...sold any supplies, materials, equipment, or other personal property to the Academy or ESP contracted by the Academy? *

Please Explain *

...guaranteed any loans for the Academy? *

Please Explain *

...been employed by the Academy, its ESP company or other contractors? *

Please Explain *

...had personal or business relationship with a current Academy board member, staff, or other faculty member? *

Please Explain *

...received, directly or indirectly, any payments, gifts, or anything else of value from the Academy, the ESP contracted by the Academy, or from anyone acting on behalf of either the Academy or the management company? *

Please Explain *

Are there situations not described above which may give the appearance of a conflict of interest between you or a member of your immediate family, or would make it difficult for you to discharge the duties of your office in an independent manner? *

Please explain *

Ethical Matters

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

(No questions will appear here if you are applying for reappointment)

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? *

Please explain *

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

Please explain *

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

Please explain *

Have you ever been convicted by any military court? *

Please explain *

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

Please explain *

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? *

Please explain *

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 see *

Please explain *

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

Please explain *

References

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

(No questions will appear here if you are applying for reappointment)

Reference 1 Name *

Reference 1 Relationship to You *

Reference 1 Phone Number *

How long have you known Reference 1? *

Reference 2 Name *

Reference 2 Relationship to You *

Reference 2 Phone Number *

How long have you known Reference 2? *

Reference 3 Name *

Reference 3 Relationship to You *

Reference 3 Phone Number *

How long have you known Reference 3? *

Recent Changes

Are there any changes from your last application that may influence your appointment?

If you selected yes, LIST ANY CHANGES FROM YOUR LAST APPLICATION THAT MAY INFLUENCE YOUR APPOINTMENT (Specifically list all changes to your Education History, Ages of your Children, Conflict of Interest and Ethical Matters.

Are there recent changes from your last application? *

Please describe the recent changes. *

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.

Signature *

By signing the field below, 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.

Date of Birth *

Maiden Names

Any previously used names?

Enter your most recent former address below:

Address Line 1 *

Address Line 2

City *

State/Province *

Zip/Postal Code *

Gender *

Ethnicity *

Signature *

By signing the field below, I agree to the above terms and assert and certify that the information provided is, to the best of my knowledge, true and complete.

Acknowledgment of Documentation Requirements

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 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 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.

Signature *

By signing the field below, I agree to the above terms and assert and certify that the information provided is, to the best of my knowledge, true and complete.

Human Verification *

Page last modified June 2, 2026

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Application - Charter School Board Member

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