Ambassador Program Application Form

Thank you for your interest in the ASLM Ambassador Program. Please complete the following application form to be considered. Ambassadors will be selected based on their alignment with ASLM’s mission and their potential impact. The ASLM Ambassador Program empowers professionals to advocate for ASLM’s mission, expand its network, and strengthen laboratory services across Africa. Ambassadors gain recognition, networking opportunities, and a platform to influence policies and innovation in laboratory medicine.

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Applicant Information

Please provide complete details for all fields below.
Salutation (Prof, Dr, Mrs., Mr., Miss, Ms. etc.)
Given name(s)
Your Name as seen on your passport
Address

Nominee Details

If nominating someone else, please complete the sections below:
Check one box:
Please describe your relevant skills and experience that make you a suitable candidate for the Ambassador Program. If nominating, provide details for the nominee. (Maximum: 300 words)
Why are you interested in becoming an ASLM Ambassador? How does this role align with your personal and professional goals? If nominating, explain how the nominee aligns with ASLM's mission. (Maximum: 300 words)
How do you plan to engage with ASLM as an Ambassador? What contributions do you expect to make, and how will you support ASLM’s mission? If nominating, describe the expected contributions of the nominee. (Maximum: 300 words)
Please provide any additional information that strengthens your application, such as any previous experience as an ambassador or in a similar role promoting a program, initiative, or organization. If nominating, describe the expected contributions of the nominee. (Maximum: 300 words)
Clear Signature
I confirm that the information provided is accurate and truthful.