College Affiliate Form
Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Alt. Phone Number
-
Area Code
Phone Number
E-mail
*
Last 4 Digits of Social Security Number
*
If non-applicable, please type 0000
Birth Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Marital Status
*
Married
Single
Gender
*
Male
Female
I choose not to disclose
Ethnic Category (voluntary for federal government reporting)
White/Caucasion
Black
Asian
Hispanic (including Puerto Rican, Mexican, Cuban, Latin American)
Native American/Alaskan Eskimo
Other
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Select Appointment Type
*
Five College Exchange/Borrow
Research Associate
UMass Graduate Student
Temporary Affiliate (Staff)
Campus Police
SSW Visiting International Scholar
Position Supervisor
*
Department
*
Reason for Requesting Access to Smith College Network
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Appointment Begin Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Appointment End Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Select Appointment Term
*
Fall
Spring
Inter-Term
Academic Year
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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)
Submit Form
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