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

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– 2016 ALSC/BOG C
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HICAGO
UBLIC
CHOOLS
ANDIDATE
DVISORY
OLLS AND
ECOMMENDATIONS
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1-16
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ALSC/BOG C
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ANDIDATE
OMINATION
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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: ___________________
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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
NO
FORM NAME
NUMBER
YES
NO
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

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