College Affiliate Form

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

Appointment Begin Date

Month Day Year
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Appointment End Date

Month Day Year
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Select Appointment Term *

Fall Spring Inter-Term Academic Year

Name of Emergency Contact *

First Name Last Name

Emergency Contact Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

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?

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Smith College Authorization Signature *

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