Confidential Registration Form
SJG – The Spelman & Johnson Group
Network of Higher Education Professionals

* denotes a required field

Please enter a valid email address as a user name. This will be the address to which SJG will send all correspondence.
Type in a password for future account access. IMPORTANT - your password must ONLY contain letters and/or numbers.
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Please be sure to add @spelmanandjohnson.com and @sjgsearch.com to your approved senders list or email "whitelist" so you don't miss our mailings.
*User Name (valid email address):
*Password (Alphanumeric ONLY - please do not use symbols):
*Confirm Password:
Your Personal Information
    *First Name
    *Last Name
    *Current Professional Title
    *Current Institution or Company
    If you work outside of higher education or your institution does not appear in the above drop down list, please check this box:
    and enter your company or institution here:
    Enter Preferred Mailing Address Below
    Street Address
    Street Address2
    City
    *State
    Zip
    Country
    *Email Address
    *Must be the same as your user name.
    Office Phone
    Home Phone
    Cell Phone
    Additional Phone
    Geographical Preference
    Please select all geographical areas in which you would consider a new position.
 Mid-Atlantic (DE, DC, MD, NJ, NY, PA)
Midwest (IL, IN, IA, KS, MI, MN, MO, NE, ND, OH, SD, WV, WI)
New England (CT, ME, MA, NH, RI, VT)
South (AL, FL, GA, KY, LA, MS, NC, SC, TN, VA)
Southwest (AR, NM, OK, TX)
West (AK, AZ, CA, CO, HI, ID, MT, OR, UT, WA, WY)

Voluntary Equal Opportunity Data

Note: Submission of this information is voluntary. SJG does not wish to collect sensitive personal information, such as age, religion, racial or ethnic origin, sexual orientation, government identity numbers such as social security or other numbers, health or medical conditions, or criminal history unless we are legally required to do so for recruiting purposes or when such information is voluntarily provided to us as part of our efforts to comply with Equal Employment Opportunity regulations or Affirmative Action requirements. Information gathered to comply with our EEO or AA obligations will be kept confidential to the fullest extent possible. SJG complies with all relevant government regulations and affirmative action responsibilities. Solely to help us with equal opportunity recordkeeping, reporting, and other legal requirements, please complete these questions.
    Ethnicity

The categories herein should not be interpreted as scientific or anthropological in nature. They were developed by the Federal government to provide for the collection and use of compatible and exchangeable thnic data by Federal agencies.

Select all that apply:

White (a person not of Hispanic origin, having origins in any of the original peoples of Europe, North Africa, or the Middle East.)

American Indian or Alaska Native (a person having origins in any of the original peoples of North America and who maintains a cultural identification through tribal affiliation or community recognition.)

Asian or Pacific Islander (a person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent or the Pacific Islands.)

Black (a person not of Hispanic origin, having origins in any of the Black racial groups of Africa.)

Cape Verdean (a person not of Hispanic origin, having origins in any of the peoples of the Cape Verde Islands.)

Hispanic (a person of Mexican, Puerto Rican, Cuban, Central American, South American or other Spanish culture or origin, regardless of race.)





White


American Indian or Alaska Native


Asian or Pacific Islander


Black


Cape Verdean


Hispanic
    Military Status

Veteran of the Vietnam Era is a person who:

(A) served on active duty for a period of more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred: (i) in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or (ii) between August 5, 1964, and May 7, 1975, in all other cases;
or

(B) was discharged or released from active duty for a service connected disability if any part of such active duty was performed: (i) in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or (ii) between August 5, 1964, and May 7, 1975, in all other cases.

Other Veteran is any other Veteran who served on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized. 		Vietnam Era Veteran
Yes No
Other Veteran
Yes No

(See Military Status definitions at left.)
    Gender
M F TG