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SOLAR SYSTEM AMBASSADORS 2015
APPLICATION FORM

Instructions

Carefully read the Announcement of Opportunity and the application form before making any entries. You may want to print a blank form to use as a worksheet. Complete the entire application and review your entries BEFORE clicking the "Submit" button.

Once submitted, your application will be automatically forwarded to the Solar System Ambassadors Program office. After the form is received, a confirmation notice will be emailed to the address provided in your application. This confirmation notice may be printed and/or saved for your records.

Questions about the application form or the Solar System Ambassadors program may be directed to the SSA Coordinator. All information provided in this application is confidential and will be used strictly for the purpose of administering the program. It will not be distributed externally for commercial use.

Note: Internet access and an email address are required for selection as a Solar System Ambassador. Only the Ambassador's name, city, state, zip code, photo and biography will be listed on the public web site. This listing is intended to aid in advertising the Solar System Ambassador's availability to conduct public events in his/her local community.

Name:

Address:
City:
State:
Zip Code:
Home Phone:
Mobile:

Occupation:
Employer:
Employers Address:
City:
State:
Zip Code:
Work Phone:
Fax:

Primary Email Address:
Please Enter Primary Email Address Again:
Secondary Email Address:

Education/Degree:
   
Institution From:
Year Awarded:

Memberships:
Awards:

Community:
Population:
Nearest City:
Distance in Miles:
Community
Volunteerism:

Why do you want to be a Solar System Ambassador?
Why is space exploration important to you?
What qualities or skills do you possess that would make you a good Solar System Ambassador?
How did you hear about the Solar System Ambassadors Program?

 Speaking and Public Engagement Experience:
 
Preferred Presentation Method:
 
Preferred Audience:
 
Preferred Venue:
 
If you use social media to promote space science, please share those accounts here (Twitter, Facebook, Google+, personal blog, etc):
 
Social Media Type
Account Name
URL (if applicable)
1.
2.
3.
4.
5.

 

How would you use social media in support of Solar System Ambassador activities? (Social media is not required for SSA acceptance. If you do not intend to use social media, mark "N/A" in the box.)

 

Short Biography (2-3 paragraphs) that could be published on the web site:

References:
 
Name
Relationship
Phone Number
1.
2.
3.
4.
5.

Proposed Public Event #1:
Topic:
Venue:
Start Date:
 
   
End Date
(if applicable):
Event
Description:
Proposed Public Event #2:
Topic:
Venue:
Start Date:
 
   
End Date
(if applicable):
Event
Description:
Proposed Public Event #3:
Topic:
Venue:
Start Date:
 
   
End Date
(if applicable):
Event
Description:
Proposed Public Event #4:
Topic:
Venue:
Start Date:
 
   
End Date
(if applicable):
Event
Description:

This page was last updated September 4, 2014
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