Form 1-16 - Alsc/bog Candidate Nomination - Chicago Public Schools

– 2016 ALSC/BOG C

HICAGO

UBLIC

CHOOLS

ANDIDATE

DVISORY

OLLS AND

ECOMMENDATIONS

ROCESS

1-16

ORM

ALSC/BOG C

ANDIDATE

OMINATION

ORM

This form and its accompanying documents must be filed in the school in which the candidate is running

by 3:00 p.m., March 4, 2016 or in the Office of Local School Council Relations by 3:00 p.m., February 19, 2016.

MAILED, E-MAILED, FAXED or COPIED FORMS WILL NOT BE ACCEPTED. (Please print all information)

School Name: _________________________________________________ Unit #: ___________ Network: _________________________________

Candidate Type:

 Parent/Legal Guardian;

 Community Resident;

 Teacher;

 JROTC Instructor;

 Advocate;

 Educational Expert;

 Student;

: _______________________________ _______________________ _____________________________

Candidate Name

LAST NAME

FIRST NAME

MIDDLE NAME OR INITIAL

Home Address: _____________________________________________ City: ____________________ State: _____ Zip Code: ________

Date of Birth: ________________________________ E-mail: ________________________________________________________________________

NOTE: Under state law, the names and addresses of Local School Council members are matters of public record.

THIS SECTION TO BE COMPLETED BY CANDIDATES FOR PARENT REPRESENTATIVE:

Name of one child who attends this school: _____________________________________________________________ Grade: ___________

IDENTIFICATION SUBMITTED

Indicate which two (2) of the following identification items were presented, photocopied, and attached to this form.

□Driver’s License

□Employer ID

□Social Security Card

□Alpha list of Parents, Guardians

□Current Lease

□Student ID

□Current Utility Bill

□Student’s Birth Certificate

□IDPA Card

□Credit Card

□Voter Registration Card

□MediPlan/Medicaid Card

□Library Card

□Matricula Consular

□Permanent Resident Card

□Other Current ID ________

List the type of identification and the ID numbers for two (2) of the above if a photocopy machine is not available.

1. __________________________________________________

2. ___________________________________________________

DISCLOSURE OF ECONOMIC INTERESTS

If elected or appointed, candidates MUST submit a complete Statement of Economic Interests within 7 days of taking office.

Are you related to the principal?

___ Yes ___ No

If YES, you CANNOT serve on this LSC.

Do you, your spouse, relatives or your company do any business with the Board of Education, the school or the

ALSC/BOG where you are running?

___ Yes ___ No

If YES, explain: ________________________________________________

STATEMENT OF VERIFICATION AND ACKNOWLEDGEMENT

I verify that the information contained in this Candidate Nomination Form and all related Candidate Forms is true and

correct to the best of my knowledge and belief.

I acknowledge that: I must complete and submit a Criminal Conviction Disclosure Form (2-16) or be subject to

disqualification from appointment to an ALSC/BOG; if appointed, I must clear a fingerprint-based Criminal Background

Investigation and must have completed sixteen (16) hours of training within six (6) months of initial appointment; I will be

subject to removal from office for noncompliance with the referenced requirements.

Candidate’s Signature: ___________________________________________________________

Date: ___________________

----

---- TEAR ALONG THIS LINE ----

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NOMINATION FORM RECEIPT

Received by: (At school): ________________________________________________________ Date: ______________ Time: _________

or by Deputy Registrar (if applicable): ____________________________________________ Date: ______________ Time: ________

School Name: _____________________________________ Candidate’s Name: _____________________________________________

School Address: ________________________________________ Unit #: __________ Network:__________________________________

_____ Nomination Forms Complete

_____ Nomination Forms Incomplete

(Check Missing Forms Below)

FORM

RECEIVED

FORM

RECEIVED

FORM NAME

NUMBER

YES

FORM NAME

NUMBER

YES

4-16

Two (2) Forms of Identification

Candidate Statement

Teacher/JROTC Instructor

1-16

5-16

Candidate Nomination

Candidate Information

2-16

6-16

Criminal Conviction Disclosure

Student Candidate Information

3-16

Telephone Number Disclosure

Form 1-16 - Alsc/bog Candidate Nomination - Chicago Public Schools - 2016

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