Ambassador Program Application

Step 1: Personal Information	Step 2: Add Picture	Step 3: Confirmation
All fields are required (unless noted)

Last Name:

First Name:

Permanent Address
Address 1:
Address 2:
City:
State/Province:
Zip Code:
Country:
Telephone # :

Current Address (Optional)
Address 1:
Address 2:
City:
State/Province:
Zip Code:
Country:
Telephone # :
How long will you be at your current address?	/ /

Email:

I would like to start an Ambassador Club in my:

School/University/Organization/Company Information
Name:
Address 1:
Address 2:
City:
State/Province:
Zip Code:
Country:
Telephone # :

Why would you like to start a United Planet Ambassador Club?

What do you hope to accomplish in your first year? Please mention 3-5 key goals.

Discuss your leadership experience. Please include your strengths and weaknesses.

Have you been involved in any community service work, organizations, movements, or other projects? If so, please give details.

Have you had any international or intercultural experiences (for example: camps and conferences in other countries, contact with people or other cultures, etc.)? If so, please give details

What is your native language?

Do you speak another language?

Please include any other language that you speak and how fluent you are at speaking this language.

Add anything else about yourself that you think is exciting. (optional)

Name of school / university / organization / work Advisor and job title.

Advisor Telephone:

Advisor Email:

List of potential members of your club:

If you still don't have potential members, how will you recruit members for a club and engage your community in the club's activities?

References
Please provide us with the names and contact information of two (2) professional or academic references. References must be from a current or past employer, teacher or professor. No family members or personal friends please. United Planet reserves the right to contact these individuals during your application process.
Name:
Relationship to you:
Telephone #:
Email Address:

Name:
Relationship to you:
Telephone #:
Email Address:

How did you hear about us?

Please specify how you heard about United Planet. Be specific if possible.

I certify that the above information is true, complete, and correct to the best of my knowledge. I represent that I have withheld nothing which, if disclosed, would affect this application unfavorably. I understand that any false statement, misrepresentation or omission made by me on my application, resume, or any other materials I have submitted, or during my interviews, can result in denial of my application, or, if I have already been accepted as participant in the Ambassador Program when such false statement, misrepresentation or omission is discovered, immediate termination of my participation in the Ambassador Program.