Michigan Department of Labor & Economic Growth	5/2006

Please submit this form no less than five (5) months prior to the effective date of change.

Office of Career and Technical Preparation

Date of Request:  ______________
Effective Date of Relocation:  ______________
CEPD #: ______________

REQUEST FOR TRANSFER OF FISCAL AGENCY, OPERATING DISTRICT AND/OR BUILDING FOR A STATE-APPROVED CAREER AND TECHNICAL EDUCATION PROGRAM

Directions:	This form must be completed and submitted to the Office of Career and Technical Preparation five (5) months prior to a fiscal agency change or an approved CTE program being transferred to another building.   Please submit a separate form for each program affected, identified by the PSN number listed in the CTEIS system.  The program identified below must meet current OCTP standards or state aid added cost might be jeopardized.  

		All courses currently approved for this program on the CTEIS system will be transferred with the approval of this request.  If additional courses will be offered, an Additional Course Offering Form must be completed.  The minimum number of minutes approved for this program must continue to be offered and reported.  

♦  Section A   Program Information (Must Be Completed)

	Established PSN (Program Serial Number)		  __  __  __  __  __

	Program CIP Code				__  __  .  __  __  __  __

Program Name											

	Number of Minutes Program Operates Per Year:  _____________

♦  Section B   (Complete if requesting Fiscal Agency or Operating District Transfer)

	*Current:     Fiscal Agency Number & Name	__  __  __  __  __	 				

*Proposed:  Fiscal Agency Number & Name	__  __  __  __  __					

*[NOTE:  If This is a Fiscal Agency Transfer Request, Both Current and Proposed 
	   Fiscal Agency Superintendents Must Sign on Page 2]
	
Current:     Operating District Number & Name	__  __  __  __  __	 				

Proposed:  Operating District Number & Name	__  __  __  __  __					

♦  Section C   (Complete if requesting a Physical Building Transfer for this state-approved CTE program)

Current:  Building Number & Name		__  __  __  __  __	 				

  Building Address:									

Proposed:  Building Number & Name 		__  __  __  __  __	 				

  Building Address:									

Please attach the following information if requesting a building transfer:

□  Rationale for Move

□  Blueprint/Outline of new classroom space with square footage and required equipment.

□  Current course syllabus, reflecting current state program standards, and alignment with the Michigan Curriculum Frameworks.

□  Copy of Instructor’s Vocational Certification/Credentials 

Page 2
Date of Request:  ______________
Effective Date of Relocation:  ______________
CEPD #: ______________

REQUEST FOR TRANSFER OF FISCAL AGENCY, OPERATING DISTRICT AND/OR BUILDING FOR A STATE-APPROVED CAREER AND TECHNICAL EDUCATION PROGRAM

♦  Section D   Contact Information and Signatures (Must Be Completed)  

Contact Person: __________________________________________________________________________

	Phone Number:     (             )                                                   Fax Number:    (              )__		___________

These signatures signify approval of this transfer, and certify that the facility housing this state-approved career and technical education program meets the accessibility regulations contained in the Americans With Disabilities Act.  

____________________________________________________________________           _______________ 
Signature of Current Fiscal Agency Superintendent 					            	Date

____________________________________________________________________           _______________ 
*Signature of Proposed Fiscal Agency Superintendent  				              Date

*[If This is a Fiscal Agency Transfer Request, Both Current and Proposed 
	   Fiscal Agency Superintendents Must Sign]

____________________________________________________________________           _______________ 
Signature of CEPD CTE Administrator                                   		                                           Date

Return Completed form to:

Glenna Zollinger-Russell, Supervisor
Career Planning and Education Unit
 Michigan Department of Labor & Economic Growth
Office of Career and Technical Preparation
Post Office Box 30712
Lansing, Michigan 48909

Phone: (517) 241-2072
Fax: (517) 373-8776

STATE USE ONLY

Approved:   									______________
                                          		Signature					           Date