Test Speakers Bureau Page – Arkansas STEM Coalition

Basic Information

Prefix

First Name

Middle Name

Last Name

Suffix

Personal Email

Cell Phone

Home Address

City

State/Province

Zip/Postal

I give permission for The Arkansas STEM Coalition to use the answers in this survey on their website and separate Speakers Bureau websites.

Would you like to subscribe to The Arkansas STEM Coalition's e-newsletter? (We send once or twice a month and will never sell or share your information.)

Demographic Info

To select multiple boxes, hold Ctrl + Right Click.

Your Gender

Your Race/Ethnicity

American Indian or Alaskan Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or Northern African

Native Hawaiian or Pacific Islander

White

Some Other Race

Prefer Not to Answer

Are you currently working, in school, or retired?

Currently working

Retired

In school

Current Company/Organization Information

Current Company or Organization Name

If you are retired, just type "retired" and we will ask you about your past job experience instead.

Current Company or Organization Mission/Description

If you are retired, just type "retired" and skip down to Past Experience.

Current Title

If you are retired, just type "retired" and we will ask you about your past job experience instead.

Give a brief description of your current job/what you actually do all day (not just a job description).

If you are retired, just type "retired" and we will ask you about your past job experience instead.

Work Email

Work Phone

Current Company or Organization Address

City

State/Province

Zip/Postal

Upload Company Logo(s)

Maximum file size: 104.86MB

Please upload your company or organization's logo. If you have multiple logos, please upload each file separately.

Immediate Past Experience

Immediate Past Company or Organization Name

Immediate Past Company or Organization Mission/Description

Immediate Past Title

Give a brief description of your immediate past job/what you actually did all day (not just a job description).

Immediate Past Company or Organization Address

City

State/Province

Zip/Postal

Do you want to enter another past experience or position?

No

Yes

Experience #2

Past Company or Organization Name

Past Company or Organization Mission/Description

Past Title

Give a brief description of your past job/what you actually did all day (not just a job description).

Past Company or Organization Address

City

State/Province

Zip/Postal

Do you want to enter another past experience or position?

No

Yes

Head Shot Upload

Maximum file size: 104.86MB

Please upload your most recent head shot. If you have multiple ones, please upload the one that you prefer we use.

Bio & CV Upload

Maximum file size: 104.86MB

Please upload your bio and/or CV. If you have multiple bios (i.e. a short and long one), please upload each file separately.

Past High School Education

I attended high school:

in Arkansas

outside of Arkansas

outside of the United States

I did not attend high school

Arkansas High Schools I attended (check all that apply):

Little Rock Central High School

Fayetteville High School

Hot Springs World Class High School

Beebe High School

Arkansas School for Science, Math, and Arts

High School Career/Technical Centers I attended (check all that apply):

Arkansas Northeastern College Technical Center (Blytheville)

Arkansas State University Beebe Regional Career Center (Searcy)

Arkansas State University Mid-South Technical Center (West Memphis)

Arkansas State University Mountain Home Technical Center (Mountain Home)

Arkansas State University Newport IGNITE Academy (Newport)

Arkansas State University Three Rivers Career Center (Malvern)

Arkansas Tech University Career Center (Russellville)

Past Higher Education

I attended higher education classes:

in Arkansas

outside of Arkansas

outside of the United States

I did not attend high school

Past Higher Education: 4-Year Colleges & Universities (check all attended):

Past Higher Education: Public 2-Year Colleges (check all attended):

Higher Education: Other Schools

Arkansas Colleges of Health Education

Criminal Justice Institute

New York Institute of Technology, College of Osteopathic Medicine - Jonesboro

Northwest Technical Institute

U of A Clinton School of Public Service

University of Arkansas for Medical Sciences

Do you have an AELS number/Case ID (for people licensed under the AR Educator Licensure System)

No

Yes

If you aren't sure, you can look it up here: https://aels.ade.arkansas.gov/AELS/Search.aspx.

Enter your AELS number or Case ID here:

If you don't know your number, you can look it up here: https://aels.ade.arkansas.gov/AELS/Search.aspx.

I am interested in/willing to do the following:

Judging student events

Hearing more about STRIVE

Getting involved with Career Blade

Rich Text

This is the field description for my Rich Text field. It is set at the Default Label Position.

Here is the newest "Section" Field I added.

Just a text box to see if the Section Header will appear at the bottom.

AR STEM Speakers Bureau

Sign up to speak with the AR STEM Speakers Bureau!

Basic Information

Demographic Info

Current Company/Organization Information

Immediate Past Experience

Experience #2

Past High School Education

Past Higher Education

Past Higher Education: 4-Year Colleges & Universities (check all attended):

Past Higher Education: Public 2-Year Colleges (check all attended):

Higher Education: Other Schools

Here is the newest "Section" Field I added.

Find a STEM Speaker

Arkansas STEM Coalition

Contact Us