College Affiliate Form

Home Address *

Email *
example@example.com
Phone Number *

- Area Code Phone Number
Date of Birth *

- Month - Day Year
Date
Last 4 Digits of Social Security Number *
If non-applicable, please type in 0000
Marital Status *

Married Single
Gender *

Male Female I choose not to disclose
Ethnic Category (voluntary for federal government reporting)

White/Caucasian Black Hispanic (including Puerto Rican, Mexican, Cuban, Latin American) Native American/Alaskan Eskimo Other option
Type a question
Position Title *
example: Research Associate, Five College Faculty, Teaching Associate, etc
Department *
Position Supervisor *
Appointment Begin Date *

- Month - Day Year
Date
Appointment End Date *

- Month - Day Year
Date
Reason for Requesting Access to Smith College Network *
Name of Emergency Contact *

First Name Last Name

Emergency Contact Address *

Emergency Contact Phone Number *

- Area Code Phone Number
Emergency Contact Relationship to You *
Relatives Employed at Smith College, if any
Please include name, relationship, and department
Display in Online Campus Directory?

Yes No
Smith College Authorization Signature *

(sign with mouse, finger, or in print) Clear
Should be Empty: