College Affiliate Form
Name
*
First Name
Middle Name
Last Name
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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
Position Title
*
example: UMASS Grad Student, 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
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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
Submit
Should be Empty: