* Required

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* 1. Surname
e.g. Smith, García, Kowalski, Silva, Müller...

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* 2. First Name
e.g. Diana, Albert, Maria, Susanna, John, Laura...

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* 3. Email address
Please make sure you write your email address correctly

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* 4. Country where you teach

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* 5. City where you teach

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* 6. Name of your school (if still teaching)

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* 7. Postal address of your school
Please write the full postal address of your school. For example:
European Schoolnet, Rue de Treves 61, 1040, Brussels, Belgium

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* 8. Are you part of the Scientix community already?

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* 9. Subjects you teach

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* 10. Age of your students
Select all the relevant ages. If not teaching any longer, choose the ages of students you have taught in the past.

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* 11. Give us one reason why you would like to be part of this project
Specially why are you interested

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* 12. Give us three reasons why you think you should you be selected to be a Scientix Ambassador for your country.
Include experience (eg. projects done, research, experience in other European projects, experience with projects' quality assurance, experience presenting at conferences, outreach / networks of teachers known/available for you...)

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* 13. Do you feel confident you would be able to carry out all the tasks planned for Scientix Ambassadors?
Please explain why/how.

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* 14. Name three science teachers’ events where you have participated in the past.
Please try to include URLs, number of attendees and other relevant information

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* 15. Please answer yes / no

  Yes No
I agree with the tasks and conditions of being a Scientix Ambassador
The school management board has agreed to support my work in the Scientix project, if I am selected
Whether I am selected or not, European Schoolnet may contact me for other projects / events
I understand that if selected I must attend the Scientix Tachers' kick-off in December 2013
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