California Department of Education

California Department of Education
Notice forCharter School Number
Revised May 2016
For CDE Use Only / Charter #: / Month/Year to SBE:
Charter School Information
School Name:
Principal or Administrator: / Phone:
Mailing Address: / E-Mail Address:
City: / Zip Code:
Grade Span: / Funding Option: / Direct Local
Site Type: / Classroom-based Instruction / Nonclassroom-based Instruction / Combination: Classroom-based %
Nonclassroom-based %
Date of Public Hearing by the Authorizing Local Educational Agency: / Date Approved by Authorizing Local Educational Agency: / Month and Year Proposed to Begin Serving Students: / Term of Charter
Start Date / End Date
Per California Education Code Section 47605.5, is this a county approved charter? / Yes No
Per California Education Code Section 47605.6, is this a countywide benefit charter? / Yes No
Per California Education Code Section 47605(j), is this a charter on appeal? / Yes No
Denying District (if applicable):
Per California Education Code Section 47605(a)(2) is this a conversion charter school? / Yes No
Name of school prior to conversion (if applicable):
Authorizing Local Educational Agency Information
Authorizer Name: / Superintendent:
E-mail Address: / County:
Is the location within the geographical boundaries of the Authorizing Local Educational Agency (LEA)? Yes No
If no, provideschool district where school will be located:
Proposed Charter School’s Location for School Facility or Business Address
Address:
City: / County: / Zip:
Certifications
I hereby certify the authorizing LEA’s governing board has reviewed and approved the charter petition pursuant to Education Code Section 47605, 47605.5, or 47605.6, in its entirety. I hereby certify this document as official written notice, as per Education Code Section 47605(i), of the approval for the proposed charter school to operate.
Authorizing LEA Superintendent’s Original Signature or Designee: / Date:
Authorizing LEA Superintendent’s Name: / Title:
I hereby certify that information provided on this form is true and correct. I hereby certify that the charter petition set forth offers a unique educational program that meets the needs of the students within the authorizing district’s geographical jurisdiction.I hereby certify that we have complied with all requirements pursuant to California Education Code sections 47605(a)(5) and 47605.1, and are able to provide evidence upon request.
Petitioner’s Original Signature or Designee: / Date:
Petitioner’s Name: / Title:
All packages must include the following:
  • Pursuant to California Education Code Section 47605(i), the petitioner shall provide written notice of approval of the petition by the governing board of the authorizing LEA.
  • One hard copy printed back to back of the full charter as approved by the authorizing LEA, any attachments or appendices, including meaningfully interested signatures, and a copy of the authorizer’s board meeting minutes of the public hearing and approving the charter school.
  • One CD or flash drive with an electronic copy of all above noted documentation.
Incomplete packages will not be forwarded to the SBE for numbering.
Mail complete Charter Submission Packages to the following address:
California Department of Education
Charter Schools Division
Attn: Charter Submission Package
1430 N Street, Suite 5401
Sacramento, CA 95814