SAASTA EXPERTS DATABASE REGISTRATION FORM PERSONAL INFORMATION Mr Mrs Ms Dr Prof Other please specify: TITLE: – FIRST NAME: SURNAME: DATE OF CONTACT INFORMATION POSTAL ADDRESS: E-MAIL ADDRESS: CONTACT CELLULAR NUMBER: NUMBER: PROFILE FIELD OF EXPERTISE: INSTITUTIONAL AFFILIATION: EDUCATIONAL QUALIFICATIONS: PREFERED LANGUAGE OF COMMUNICATION: OTHER LANGUAGE PROFIENCIES: SCIENCE COMMUNICATION EXPERIENCE: Public Presentation Reviewer Writer Radio Television Blogger MEDIA ARE YOU INTERESTED IN DISCUSSING YOUR WORK WITH THE MEDIA: Yes No YOU BE INTERESTED IN BEING TRAINED TO COMMUNICATE WITH THE MEDIA? Yes No PROPOSED COLLABORATIONS Role Modelling AS A PROFESSIONAL, WOULD YOU BE INTERESTED IN COLLABORATING IN ANY OF THE Workshop Sessions FOLLOWING: Lectures By completing this form you to be included in our database of content specialist and expert’s database. The database will not be accessible to the public. SAASTA takes the protection of Personal Information in terms of the Protection of Private Information Act 4 of 2013 very seriously and for this reason we take all reasonable measures to protect your Personal Information and to keep it confidential. The contents and contact information will not be used without your consent.
SAASTA EXPERTS DATABASE REGISTRATION FORM PERSONAL INFORMATION TITLE: Mr Mrs Ms Dr Prof Other – please specify: FIRST NAME: SURNAME: DATE OF CONTACT INFORMATION POSTAL ADDRESS: E-MAIL ADDRESS: CONTACT NUMBER: CELLULAR NUMBER: PROFILE FIELD OF EXPERTISE: INSTITUTIONAL AFFILIATION: EDUCATIONAL QUALIFICATIONS: PREFERED LANGUAGE OF COMMUNICATION: OTHER LANGUAGE PROFIENCIES: SCIENCE COMMUNICATION EXPERIENCE: Public Presentation Reviewer Writer Radio Television Blogger MEDIA ARE YOU INTERESTED IN DISCUSSING YOUR WORK WITH THE MEDIA: Yes No YOU BE INTERESTED IN BEING TRAINED TO COMMUNICATE WITH THE MEDIA? Yes No PROPOSED COLLABORATIONS AS A PROFESSIONAL, WOULD YOU BE INTERESTED IN COLLABORATING IN ANY OF THE FOLLOWING: Role Modelling Workshop Sessions Lectures By completing this form you to be included in our database of content specialist and expert’s database. The database will not be accessible to the public. SAASTA takes the protection of Personal Information in terms of the Protection of Private Information Act 4 of 2013 very seriously and for this reason we take all reasonable measures to protect your Personal Information and to keep it confidential. The contents and contact information will not be used without your consent.
saasta_experts_database_form.docx