Fillable Form 2PCSGP Application Cover S: heet (California)

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Form 2PCSGP Application Cover S: heet (California)

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The Form 2PCSGP Application Cover S: heet (California) form is 4 pages long and contains:

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  • 8 check-boxes
  • 125 other fields

Country of origin: US
File type: PDF

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Form 2–PCSGP Application Cover S
heet
Ch
arter School Information
Charter School Name:
Address: City:
Zip Code:
County:
Telephone Number:
County District School (CDS) Code:
DUNS Number:
Charter Authorizing Agency Name:
Date of Most Recent Charter Approval:
Charter School Number:
School Grade Levels:
Proposed/Current Enrollment:
School Opening Date:
Type of Sub-grant:
Sub-grant amount requested:
Is this school a conversion school?
Yes No
Is the school managed by a Charter Management Organization (CMO)?
Yes No
If applicable, name of the CMO:
1 of 4
List all governing board members of charter school:
List the names of all charter schools for which the above the governing board
members are responsible. Enter charter school names, charter numbers and CDS
codes:
Have any of the principal parties submitting this application been involved in the
development or operation of any other charter school(s) and received a PCSGP award?
Y
es
2 of 4
No
#
#
#
#
#
#
#
#
#
#
If yes, please list up to 10 of the most recent schools, including charter name,
charter number, and start and end dates of the PCSGP grant(s) below:
Has this charter school previously operated under a different name or a different authorizer?
Yes
No
If yes, please provide a brief explanation below:
3 of 4
#
#
#
#
#
#
#
#
#
#
Primary Applicant Information
Full Name: Title:
A
ddress:
City
:
State:
Zip Code
: Telephone:
Email:
Contact Person Information
Full Name:
Title:
Address:
City: State:
Zip Code:
Telephone:
4 of 4
Email:
Certification, Assurance, and Signature Section
CERTIFICATION/ASSURANCE
: As
the
duly
authorized
representativ
e
of
the
applicant,
I
have
read
all
assurances, certifications, terms, and conditions associated with the Federal
Charter Schools Program, and I agree to comply with all requirements as a condition of
funding.
I certify that all applicable state and federal rules and regulations will be observed and that to
the best of my knowledge, the information contained in this application is correct and
complete.
Printed Name of Administrator or Designee:
Telephone Number:
Date:
Administrator or Designee Signature (Blue Ink):
Prepared by the Charter Schools Division
Last modified February 2020
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Form 2PCSGP Application Cover S: heet (California)

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Completed 22 February 2021

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