Ocean Allies Role Model Intake Form

1
Are you nominating yourself or someone else?
Myself
Someone else
2
If you’re filling out this form for someone else, please share your information below. If you’re filling out this form for yourself, skip this section:
First and Last Name:
Place of employment:
Email address:
Relationship to nominee:
3
Name:
First Name
Last Name
4
Place of Employment:
5
Associated Ocean Sector:
Please Select
Please Select
Academic Research
Research and Development
Nonprofit
Fisheries/Aquaculture
Other (please specify)
6
Location:
7
Do you self-identify as belonging to an equity deserving community:
YESNO
8
Photo Upload (optional):
9
Photo Consent: If selected as an Ocean Allies role model, I agree for my photo to be used within the role model program and Ocean Allies marketing materials.
YESNO
10
Email:
example@example.com
11
LinkedIn:
12
Book your role-model Interview* This field is required.Before approving you as a role model, we'd like to learn a little bit more about you! Please book an interview time that works for you using the calendar below. Note: Depending on our availability, we can't guarantee the exact time slot, but we will get as close as possible.
Should be Empty: