DEIA Advisory Application Name(Required) First Last Email(Required) Phone(Required)OrganizationJob TitlePlease select one of the following: Self Nomination Nomination on someone else’s behalf If you are nominating someone else, have they agreed to participate on this Advisory Board? Yes No Please select the option that best describes your gender:(Required)FemaleMaleGender Variant/Non-ConformingOtherPrefer not to respondAre you of Hispanic, Latino, or Spanish origin?(Required) No, I am not of Hispanic, Latino, or Spanish origin. Yes, I am of Hispanic, Latino, or Spanish origin. Prefer not to respond What is your race? (Select all that apply.)(Required) White Black or African American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander Other Prefer not to respond Please list the languages in which you are fluent:(Required)Please specify your fluency in oral communication, reading and/or writing. Specific Industry SkillsHave you ever worked in or for commercial fishing, forestry, or agricultural production?(Required) Yes No Do you work in healthcare or as a healthcare provider?(Required) Yes No Are you a safety professional?(Required) Yes No Are you an educator or researcher?(Required) Yes No List any other skills or life experiences you have that you feel are relevant to this work:Please describe your experience working with the following populations:Individuals with Disabilities(Required) Very Experienced Somewhat Experienced Limited Experience No Experience Women in Agriculture(Required) Very Experienced Somewhat Experienced Limited Experience No Experience Veterans(Required) Very Experienced Somewhat Experienced Limited Experience No Experience Black, Indigenous, and People of Color (BIPOC)(Required) Very Experienced Somewhat Experienced Limited Experience No Experience Migrant, Immigrant, or Diverse Ag Communities(Required) Very Experienced Somewhat Experienced Limited Experience No Experience LGBTQIA+ Individuals(Required) Very Experienced Somewhat Experienced Limited Experience No Experience Youth in Agriculture(Required) Very Experienced Somewhat Experienced Limited Experience No Experience Have you developed programs or services for diverse populations?(Required) Yes No Please describe the programs or services for diverse populations you've developed:(Required)Briefly describe why you think you would be an ideal candidate to serve on this Advisory Board:(Required)How did you hear about this opportunity?(Required) Webinar Newsletter Friend/Colleague Web Search Conference Media/News Other Resume or Other DocumentsPlease provide your resume or other documents to help us understand your background.Max. file size: 500 MB.
