Reader/Notetaker Application Form

SERVICES TO STUDENTS WITH DISABILITIES California State University, Sacramento

STUDENT JOB APPLICATION P l e a s e p r i n t c l e a r l y a n d c o m p l e t e b o t h s i d e s i n i n k NAME ______DATE _____/_____/_____ (LAST) (FIRST) (MI)

ADDRESS______Sac State ID _____-_____-______(STREET) (APT #)

CITY/STATE______ZIP______PHONE (home) (____)______

E-MAIL______PHONE (other) (____)______

APPLYING FOR: ____ READER ____ NOTETAKER ____ TUTOR (specify course according to job announcement) ______OTHER (specify position according to job announcement) ______

EDUCATION

UNIVERSITY/COLLEGE: CSUS__ OTHER__ GPA: MAJOR______OVERALL_____

STATUS: GRAD ____ UNDERGRAD ____ 1st YR_____ 2nd/3rd YR_____ 4th YR or more____

Anticipated graduation date: ______

AREAS OF STUDY: UNDERGRADUATE MAJOR______MINOR______

GRADUATE (if applicable)______

EMPLOYMENT

LIST ANY CURRENT ON-CAMPUS SAC STATE EMPLOYMENT

Department ______Job title: ______

Hours per Week______As of month______year______

LIST ANY EXPERIENCE RELATED TO THE POSITION (i.e., reading, notetaking, experience with people with disabilities): ______

______

______PROVIDE TWO PROFESSIONAL REFERENCES (Employment or Academic)— REQUIRED ! NOTE: In-state referrals are recommended

APPLICANTS MUST COMPLETE THE ATTACHED AVAILABILITY SCHEDULE.______Rev 8/07 SERVICES TO STUDENTS WITH DISABILITIES California State University, Sacramento

STUDENT JOB APPLICATION P l e a s e p r i n t c l e a r l y a n d c o m p l e t e b o t h s i d e s i n i n k Name______Title______Phone ( ) ______

Name______Title______Phone ( ) ______

AREAS/SUBJECTS

I WOULD BE BEST SUITED AT WORKING WITH STUDENTS IN THE FOLLOWING AREAS/SUBJECTS:

______TECHNICAL (i.e., Math, Physics) ______LITERARY (Novels) ______HISTORICAL/THEORETICAL

______OTHER (Specify) ______ANY OF THESE

I WOULD LIKE TO TUTOR IN THE FOLLOWING SUBJECTS OR COURSES IN WHICH I HAVE RECEIVED A MINIMUM GRADE OF “B+”:

COURSE GRADE AUTHORIZED SIGNATURE OF DEPT. CHAIR**

1)______

2)______

3)______

**Transcripts may be provided in lieu of Dept. Chair Signature. If no transcript provided, and course completed at Sac State, your signature on this application indicates authorization to access Sac State records.

SKILLS/INTEREST

INDICATE APPLICABLE SKILLS OR EXPERIENCE (SUBJECT TO VERIFICATION): BRAILLE____ SIGN LANGUAGE_____ TEST PROCTOR_____ TUTORING_____

INDICATE WHY YOU ARE INTERESTED IN THIS POSITION: ______

______

PLEASE PROVIDE ANY ADDITIONAL COMMENTS OR INFORMATION ABOUT YOUR SKILLS OR ABILITIES TO PERFORM THIS TYPE OF WORK: ______

______

I CERTIFY THAT ALL INFORMATION ON THIS APPLICATION IS CORRECT, AND THAT I HAVE ANSWERED ALL QUESTIONS TRUTHFULLY. I UNDERSTAND THAT FAILURE TO COMPLETE ALL SECTIONS OF THE APPLICATION MAY LEAD TO AN UNPROCESSED APPLICATION.

______

APPLICANTS MUST COMPLETE THE ATTACHED AVAILABILITY SCHEDULE.______Rev 8/07 SERVICES TO STUDENTS WITH DISABILITIES California State University, Sacramento

STUDENT JOB APPLICATION P l e a s e p r i n t c l e a r l y a n d c o m p l e t e b o t h s i d e s i n i n k APPLICANT’S SIGNATURE DATE

APPLICANTS MUST COMPLETE THE ATTACHED AVAILABILITY SCHEDULE.______Rev 8/07