Maine 4-H STEM Ambassadors Application

References

List two - three persons not related to you who have a definite knowledge of your qualifications. Current faculty at your university are acceptable as references. Include complete addresses and email for each.

Reference 1: Name

First Last

Reference 1: Email

Enter Email Confirm Email

Reference 1: Phone

Reference 1: Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Reference 2: Name

First Last

Reference 2: Email

Enter Email Confirm Email

Reference 2: Phone

Reference 2: Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Reference 3: Name

First Last

Reference 3: Email

Enter Email Confirm Email

Reference 3: Phone

Reference 3: Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

May we contact other references suggested to us in the course of contacting the references listed above?*

Yes
No

Please note: information received from any references will be considered as a part of your application.

In-Person Training

October 1 - 10:00 am - 12:00 pm
October 1 - 2:00 pm - 4:00 pm
October 3 - 2:30 pm - 4:30 pm
October 7 - 10:00 am - 12:00 pm
October 7 - 2:00 pm - 4:00 pm

Select all times that work for your schedule.

Have you ever been convicted of any crime other than a minor traffic violation?*

Yes
No

If yes, please describe:

I authorize contact of listed references. I understand that misrepresentation or omission of facts requested is cause for non-appointment or termination as a Cooperative Extension volunteer. I agree toa bide by the expectations of Cooperative Extension and to fulfill the volunteer responsibilities to the best of my ability.

STEM Ambassador Signature*

Please type your first and last name; understand that typing your name constitutes a legal signature confirming that you acknowledge and agree to the above statement.

Upon hitting submit, you will be directed to the required University of Maine Background Check. Please email 4-HScience@maine.edu and let us know when you have submitted that form.

Name

This field is for validation purposes and should be left unchanged.

Cooperative Extension: 4-H