Form 1-16 - Lsc Candidate Nomination - Chicago Public Schools

– 2016 L

HICAGO

UBLIC

CHOOLS

OCAL

CHOOL

OUNCIL

LECTION

1-16

ORM

LSC 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: _______________________________________________________ Network: _____________________________________________

Candidate Type

 Parent/Legal Guardian;

 Community Resident;

 Teacher;

 Non-Teacher Staff;

 Student

: _______________________________ _______________________ _____________________________

Candidate Name

LAST NAME

FIRST NAME

MIDDLE NAME OR INITIAL

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

Date of Birth: ________________________________ E-mail: ________________________________________________________________________

NOTES: Community member candidates must provide proof of current residency within the school's attendance area or voting district.

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 LSC

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 (Form 2-16) or be subject to

disqualification from election or appointment to an LSC; if elected or appointed, I must clear a fingerprint-based Criminal

Background Investigation and must complete sixteen (16) hours of training within six (6) months of taking office; I will be

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

Candidate’s Signature: ___________________________________________________________

Date: ___________________

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---- 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: ________________________________________

Were Two Forms of Identification Provided? ______________ Yes; ____________________ No.

_____ Nomination Forms Complete

_____ Nomination Forms Incomplete

(Check Missing Forms Below)

FORM

RECEIVED

FORM

RECEIVED

FORM NAME

NUMBER

YES

FORM NAME

NUMBER

YES

1-16

4-16

Candidate Nomination

Candidate Statement

Teacher/Non-teacher Staff Candidate

2-16

5-16

Criminal Conviction Disclosure

Information

3-16

6-16

Telephone Number Disclosure

Student Candidate Information

Form 1-16 - Lsc Candidate Nomination - Chicago Public Schools - 2016

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