1. Indicate whether you, your spouse or other immediate family members have, anticipate in the future, or have been offered a direct or indirect 3. Indicate any potential ethical or legal conflicts of ownership, employment, contractual or management interest that would (or are likely to) exist for you as a interest in the provider. For any interested indicated, member of the School Board or another School or please provide a detailed description. board. [Note that being a parent of a School I/we have no such interest. student, serving on another charter School’s board or Yes being employed by the School are conflicts for certain issues that should be disclosed.] None Yes. If yes, please provide additional 2. Indicate if you, your spouse or other immediate information. family member anticipate conducting, or are conducting, any business with the provider. If so, indicate the precise nature of the business that is being or will be conducted. Disclosures for Schools Contracting with an I/we do not anticipate conducting any such Educational Service Provider business. Yes 1. Indicate whether you, your spouse, or any immediate family member knows (i.e., beyond a casual or professional acquaintance) any employees, officers, owners, directors or agents of that provider. If the answer is in the affirmative, describe any such Other relationship. I/we do not know of any such persons. 1. I affirm that I have read the charter school’s Bylaws Yes and conflict of interest policies. I affirm Conflicts for Schools Contracting with an Educational Service Provider I, _________________________________________, certify to the best of my knowledge and ability that the information I am providing to the _______________________________ [District] in regard to my application to serve as a member of the board of directors of the _________________________________ Charter School is true and correct in every respect. Signature Date Attachment 5: Education Service Provider (ESP) Agreement Guidelines Not Applicable
3. Indicate any potential ethical or legal conflicts of interest that would (or are likely to) exist for you as a member of the School Board or another School or board. [Note that being a parent of a School student, serving on another charter School’s board or being employed by the School are conflicts for certain issues that should be disclosed.] None Yes. If yes, please provide additional information. Disclosures for Schools Contracting with an Educational Service Provider 1. Indicate whether you, your spouse, or any immediate family member knows (i.e., beyond a casual or professional acquaintance) any employees, officers, owners, directors or agents of that provider. If the answer is in the affirmative, describe any such relationship. I/we do not know of any such persons. Yes Conflicts for Schools Contracting with an Educational Service Provider 1. Indicate whether you, your spouse or other immediate family members have, anticipate in the future, or have been offered a direct or indirect ownership, employment, contractual or management interest in the provider. For any interested indicated, please provide a detailed description. I/we have no such interest. Yes 2. Indicate if you, your spouse or other immediate family member anticipate conducting, or are conducting, any business with the provider. If so, indicate the precise nature of the business that is being or will be conducted. I/we do not anticipate conducting any such business. Yes Other 1. I affirm that I have read the charter school’s Bylaws and conflict of interest policies. I affirm I, _________________________________________, certify to the best of my knowledge and ability that the information I am providing to the _______________________________ [District] in regard to my application to serve as a member of the board of directors of the _________________________________ Charter School is true and correct in every respect. Signature Date Attachment 5: Education Service Provider (ESP) Agreement Guidelines Not Applicable
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