Member
Ambassador
Program

Building Healthy Communities

Company Information

Company Name

Business Phone

Applicant Information

First Name

Last Name

Title

Applicant Phone

Email

HR / Management Referral Contact Information

First Name

Last Name

Title

Phone

Email

What’s your motivation for becoming a UnitedAg Ambassador?

Briefly explain the skills and/or experiences that will help you in your role as a UnitedAg Ambassador.

Would you consider yourself to be influential at your organization? If so, please explain.

Do you have any conflicts that prevent you from committing to bi-monthly program callsand travel twice a year? If so, please explain.

Agreement

I hereby certify that all information provided in this application is true and correct.

I agree.

Output

Contact Christina Morley at cmorley@unitedag.org or call 800.223.4590.