ED - GRS (201 4 - 201 5 ) Page 1 of 2 

### 201 **4 -**  **201 5**  **District Nominee**  **Presentation Form CERTIFICATION**  **S District**  **’s Certifications**  The signatures of the district superintendent on the next page certif y that each of the statements below concerning the district’s eligibility

and compliance with the following requirements is true and correct to the best of the superintendent’s knowledge . 1. The district has been evaluated and selected from among districts within the Nominating Authority’s jurisdiction, based on high achievement in the three ED - GR S Pillars : 1) reduced environmental impact and costs ; 2) improved health and wellness ; and 3) effective environmental education . 2. The district is providing the U.S. Department of Education Office of Civil Rights (OCR) access to information necessary

to inv estigate a civil rights complaint or to conduct a district wide compliance review. 3. OCR has not issued a violation letter of findings to the school district concluding that the nominated school district has violated one or more of the civil rights statutes . A violation letter of findings will not be considered outstanding if OCR has accepted a corrective action plan to remedy the violation. 4. The U.S. Department of Justice does not have a pending suit alleging that the school district has violated one or more of the civil rights statutes or the Constitution’s equal protection clause. 5. There are no findings of violations of the Individuals with Disabilities Education Act in a U.S. Department of Education monitoring report that apply to the school district in question; or if there are such findings, the state or school district has corrected, or agreed to correct, the findings. 6. The district meet s all applicable federal, state , local and tribal health, environmental and safety requirements in law, regulations an d policy and is willing to undergo EPA on - site verification. 

### U.S. Department of Education **Green Ribbon Schools 201**  **4 -**  **2015 District Sustainability Award**  Name of Superintendent : (Specify : Ms., Miss, Mrs., Dr., Mr., etc.) (As it should appear in the official records) District Name : (As it should appear on an award) Address : Telephone: Fax: Web site/URL: E - mail: I have reviewed the information in this application and certify that to the best of my

k nowledge all information is accurate. Date : ( Superintendent’s Signature )ED - GRS (201 4 - 201 5 ) Page 2 of 2 **Nominating Authority ’s**  **Certifications** The signature b y the Nominating Authority on this page certifies that each of the statements below concerning the district’s eligibility

and compliance with the following requirements is true and correct to the best of the Authority ’s knowledge . 1. The district is one of those overseen b y the Nominating Authority which is highest achieving in the three ED - GRS Pillars : 1) reduced environmental impact and costs ; 2) improved health and w ellness ; and 3) effective environmental education . 2. The district meet s all applicable federal civil rights and federal, state , local and tribal health, environmental and safety requirements in law, regulations and policy and is willing to undergo EPA on - sit e verification . Name of Nominating Agency : Name of Nominating Authority : (Specify : Ms., Miss, Mrs., Dr., Mr., Other) I have reviewed the information in this application and certify to the best of my

knowled ge that the school meet s the provisions above. Date : (Nominating Authority’s Signature) **SUMMARY AND DOCUMENTATION OF NOMINEE’S ACHIEVEMENTS**  Provide a coherent "snapshot" that describes how your district is representative of your jurisdiction ’s highest achieving green school efforts. Summarize your strengths and accomplishments in all three Pillars and nine Elements . Then, include documentation and concrete examples for work in every Pillar and Element. **SU BMISSION**  The nomination package , including the signed certifications and documentation of evaluation in the three P illars should be convert ed to a PDF file and emailed to green.ribbon.sch ools@ed.gov according to the instructions in the Nominee Submission Procedure . OMB Control Number: 1860 - 0509 Expiration Date: February 28, 2015 **Public Burden Statement** According to the Paperwork Reduction Act of 1995, no persons are required to respon d to a collection of information unless such collection display s a valid OMB control number. The valid OMB control number for this information collection is 1860 - 0509. Public reporting burden for this collection of information is estimated to average 37 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain or retain benefit P.L . 107 - 110, Sec. 501, Innovative Programs and Parental Choice Provisions. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Education, 400 Maryland Ave., SW, Washington, DC 20202 - 4536 or email I CDocketMgr@ed.gov and reference the OMB Control Number 1860 - 0509 . Note: Please do not return the completed ED - Green Ribbon Schools a pplication to this address.