File:  LBD-E -  Intent to Apply to Become a District Charter School

Instructions:  All district charter school applicants must file this intent to apply form with the district at least 60 days before submitting an application to the Board of Education. The intent to apply form may be returned by fax to 970-368-1049 or deliver to 150 School Road, Frisco, CO. 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:  _______________________

E-mail:  _________________________________________________________

________________________________________________________________

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):  ____________________________________________________________________

2.  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):  ________________________

3.  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):  ________________________

4.  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 __________________.

Adopted August 28, 2012