Science Provider File Form
Purpose: The Science Provider Profile Form will allow registered users of the Science Provider Network to have access to the following contact information to book a program and/or publicize an upcoming program to the media and public.
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Contact Information
Name *
Name of Business/University/Corporation/Research/Association
(if applicable)
Address *
City *
State *
Zip Code *
Telephone *
Cell phone
Email *
Emergency Contact Information
Name
(optional)
Telephone
(optional)
Email
(optional)
Geographic area where you would consider presenting:
(check all that apply)
Area(s) of Expertise
(no more than 25 words)
Avocational or professional?
(click one)
Clear selection
Education
(click one)
Clear selection
Retired or active in field?
(click one)
Clear selection
Brief Biography
(150 words or less)
Experience Speaking with General Audiences
(click one)
Clear selection
Recommended Science Literature related to your presentation topic(s)
(specify up to 3)
Youth
Book titles (specify up to 3)
Teens
Book titles (specify up to 3)
Adults
Book titles (specify up to 3)
Youth
Name of Website/Website Address (specify up to 3)
Teens
Name of Website/Website Address (specify up to 3)
Adults
Name of Website/Website Address (specify up to 3)
Thank you for your participation! When you have hit “submit,” Cornerstones of Science will send you an e-mail confirmation of your registration with more details to help you plan future library presentations.
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