The City University of New York 

 

THE OFFICE OF STUDENT DISABILITY SERVICES 

 

NOTETAKER/READER APPLICATION FORM 

 

 DATE: ______________________ 

 

NAME: _______________________________________________________________ 

 

ADDRESS: ____________________________________________________________ 

 

_______________________________________________________________________ 

 

TEL. NO: (HOME #) __________________ (CELL #) ________________________ 

 

E-MAIL ADDRESS: ____________________________________________________ 

 

SOCIAL SECURITY: ___________________________________________________ 

 

MAJOR: _________________________ MINOR: ________________________ 

 

G.P.A: _____________________________ 

 

HAVE YOU WORKED ANYWHERE ON CAMPUS WITHIN THE LAST 3 
YEARS FOR WHICH YOU RECEIVED PAYMENT? YES_______ NO_______ 

 

I AM APPLYING FOR ONE OF THE FOLLOWING POSITIONS: 

(Please check one) 

 

NOTETAKER _______ PEER NOTETAKER ________ READER _________ 

 

 

 

 

______________________________________________________________________________________
SIGNATURE 

 

 

Shuster Hall, Room 238, 250 Bedford Park Blvd. West, Bronx, NY 10468 

Phone: (718) 960-8441 Fax: (718) 960-7489 E-mail: disabilities.services@lehman.cuny.edu 


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The City University of New York 

 

OFFICE OF STUDENT DISABILITY SERVICES 

 

NOTETAKER ASSIGNMENT FORM 

 

 

SEMESTER: _______________ 

 

NAME: _______________________________ S.S.#: ____________________ 

 

ADDRESS: _____________________________________________________ 

 

 _____________________________________________________ 

 

TITLE: __________________________________________________________ 

 

TITLE CODE: ____________________________________________________ 

 

DATE OF HIRE: __________________________________________________ 

 

APPOINTMENT: __________________________________________________ 

 

TOTAL HOURS: ____________________ SALARY RATE: ______________ 

 

TOTAL BUDGETED: ______________________________________________ 

 

START DATE: ___________________ END DATE: ____________________ 

 

ASSIGNED TO WORK WITH: (Student’s Name, Class, Time) 

 

1. __________________________ _____________ ____________________ 

 

2. __________________________ _____________ ____________________ 

 

3. __________________________ _____________ ____________________ 

 

4. __________________________ _____________ ____________________ 

 

5. __________________________ _____________ ____________________