Name
Phone #:
Date:
Guttman Empl ID:
Guttman E-mail:
Personal Email:
Employment Goal: (Check all that apply)
Are you currently working?
Do you have a current resume?
Are you currently registered with the Office of AccessABILITY Services?
Currently open case with ACCES-VR?
If yes, ACCES-VR Counselor, Please provide the contact information:
Are you currently working with other agencies/organizations that provides academic support services?
What is your current program of study you intend to pursue at Guttman?
Which LEADS Services are you interested in receiving? (Please check off all that apply)
RELEASE STATEMENT: I authorize the exchange of information between CUNY LEADS, Guttman Advisor, Staff and Faculty, ACCES-VR and Employers on my behalf.