PCSGP Form 1 - Application Cover Sheet (Required in Application)

[Replace this text with the school name in the document header here]

California Department of Education

Charter Schools Division

Public Charter Schools Grant Program (PCSGP)

Application for Funding

APPLICATION RECEIPT DEADLINE

Applications must be delivered to the Charter Schools Division (not postmarked) by

October 12, 2012, 4:30 p.m.

Submit to:

Charter Schools Division

California Department of Education

1430 N Street, Suite 5401

Sacramento, CA 95814-5901

NOTE: Please type all information.

Charter School Information
Charter School Name
Address
City / Zip Code
County / County District School Code
Telephone Number / Fax Number
Charter Authorizing Agency Name
SBE Charter School Number / School Grade Level
Charter School Approval Date (if you do not have an SBE number)
School Opening Date / Proposed Enrollment
School Type:
Classroom Non-classroom / Newly Established School
Conversion School
Name of Grant Application Organization (complete only one)
Non-profit Entity
(enter corporation name)
County Office of Education
School District
Primary Applicant Information
First Name
/ Last Name
Title
Address
City
/ State
/ Zip Code
Telephone Number
/ Fax Number
/ E-mail Address
Contact Person Information
First Name
/ Last Name
Title
Address
City
/ State
/ Zip Code
Telephone Number
/ Fax Number
/ E-mail Address
Grant Award Information (indicate amount requested in the appropriate box below)
The charter school is non-classroom based and eligible for funding up to $250,000. / The charter school is classroom based and eligible for funding up to $375,000. / The charter school is classroom based and eligible for a higher sub-grant award amount, up to $575,000; or
The charter school is non-classroom based and eligible for a higher sub-grant award amount, up to $375,000.
$ / $ / $
Higher sub-grant award applicants must complete and include Form 3.
Certification, Assurance and Signature Section
CERTIFICATION/ASSURANCE: As the duly authorized representative of the applicant, I have read all assurances, certifications, terms, and conditions associated with the Federal PCSGP 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
Administrator or Designee Signature (Blue Ink) / Date

Instructions

Type the information in all applicable sections. If school information such as the County District School (CDS) code number is not known, information it can be identified at the California School Directory Web site located at http://www.cde.ca.gov/re/sd/. Search for part of the school name. The search results page will contain useful information in completing the application. If this information is incorrect, follow the procedure on the Web page to submit corrections to the office that manages the schools directory information.

Important: Enter the school name in the document header to ensure that all pages of the application can be traced back to the same application package.

Charter School Information Section

Charter School Name

Type the official charter school name exactly as it appears on the California School Directory.

Address, City, Zip Code, County Fields

Type the information where the charter school is located.

County District School Code

Type the 14-digit CDS code for the school.

Telephone and Fax Number Fields

Type the school phone and fax numbers where staff can be reached during business hours.

Charter Authorizing Agency Name

Type the name of the charter school authorizing agency. The authorizing agency is listed in the California School Directory in the “District” field.

School Grade Level

Type the school grade range for students served listed in the California School Directory. The grade level information is listed on the individual Schools Directory search results pages in the “Low Grade” and “High Grade” fields.

State Board of Education Charter School Number

Type the charter school number assigned by the State Board of Education (SBE). The charter number is listed in the California School Directory in the “Charter Number” field. If the charter school has not received an SBE charter school number as of the date of application, type “pending authorization”.

Charter School Approval Date

If you do not yet have an SBE number, enter the date the authorizing agency approved the charter petition. If the charter school petition has been submitted, and has not been authorized at the time of PCSGP application, enter the text “petition submitted on [enter the petition submission date here] date - pending approval at [enter the name of the local educational agency here].”

If the charter petition was denied by a local educational agency and is submitted to a higher agency pending appeal, then enter the text “petition submitted on [enter the petition appeal submission date here] date – denied, pending appeal at [enter the name of the county office of education or SBE here].”

School Opening Date

Type the date the school opened and was available to start serving students. The open date is listed on the individual California School Directory search results pages in the “Open Date” field.

Proposed Enrollment

Type the projected first year school enrollment.

School Type (Classroom or Non-classroom)

Type if the school is “classroom based” or “non-classroom based”.

Newly Established or Conversion School

If the school is a new school that was never open before, type “new school”. If the school is a converted public school, type “conversion school”.

Name of Grant Application Organization Section (complete only one)

In only one of the option fields in this section, enter the legal/official name of the organization applying for the grant. Type data in one of the three fields listed below:

·  Non-Profit entity

·  County Office of Education

·  School District

Primary Applicant Information Section

First Name, Last Name, Title, Address, City, State, Zip Code Fields

Type the primary grant applicant information.

Telephone Number, Fax Number, E-mail Address Fields

Type the primary grant applicant telephone/fax numbers, and E-mail address where they can be reached during business hours.

Contact Person Information Section

First Name, Last Name, Title, Address, City, State, Zip Code Fields

Type the contact person information. Important: this is the person that PCSGP staff can reach for information during business hours.

Telephone Number, Fax Number, E-mail Address Fields

Type the contact person telephone/fax numbers, and E-mail address where they can be reached during business hours.

Grant Award Information Section

In only one of the three options in this section, type the amount requested.

·  Non-classroom based (eligible for funding up to $250,000)

·  Classroom based (eligible for funding up to $375,000)

·  Higher sub-grant award options

o  Classroom based higher sub-grant award amount (eligible for funding up to $575,000)

o  Non-classroom based higher sub-grant award amount (eligible for funding up to $375,000)

Certification, Assurance and Signature Section

Printed Name of Administrator or Designee

Type the charter school administrator or designee name.

Telephone Number

Type the charter school administrator or designee telephone number.

Administrator or Designee Signature

·  In the printed application submitted to the CDE, provide the administrator’s or designee’s signature in blue ink.

·  In the electronic copy of the application submitted to the CDE, type “signature on file”.

·  In the copy of the application retained at the local charter school site, ensure that the administrator’s or designee’s signature in blue ink is on file for site visit review.

Date

Type the date the document is signed.

Public Charter Schools Grant Program

Charter Schools Division Page 2 of 5

California Department of Education PCSGP-1 (Rev. 09/26/2012)