The Solar System Ambassadors Program

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SOLAR SYSTEM AMBASSADORS 2010
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 before filling in the online form. Complete the entire application, review your entries, then click on the "Submit" button below the form. Upon clicking the Submit button, your completed form will be forwarded automatically to the Solar System Ambassadors Coordinator by email. When the form is submitted, you will receive a confirmation notice. This may be printed and/or saved for your records. Questions about this form or the Solar System Ambassadors program may be directed to the 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 an Ambassador. After selection, the Solar System Ambassador's name, city, state, zip code, and primary email address ONLY will be listed on the public web site in the "Meet the Ambassadors" section. This listing is intended to advertise the Solar System Ambassador's availability for public events in his/her local community.

Name:

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

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:
Your Community Experience:

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

Nearest University:
Phone:		Zip Code:
University Contact:		Title:

Nearest Museum:
Phone:		Zip Code:
Museum Contact:		Title:

Nearest Planetarium:
Phone:		Zip Code:
Planetarium Contact:		Title:

Local Newspaper:		Circulation:
Address:
City:		State:
		Zip Code:
Email:
Phone:		Fax:

Why do you want to be a Solar System Ambassador?

Why is space exploration important to you?

What qualities or skills do you posses 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:

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 November 23, 2009

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