CENTER FOR STUDENTS WITH
Student Personnel Services
One Education Drive
Garden City, NY 11530-6793
COMPLETE ONLY IF CLAIMING AN ACCOMMODATION FOR A DISABILITY
PLEASE READ CAREFULLY
If you have a disability and believe you are entitled to any accommodations listed below AND you are certain that
you want to use them, YOU ARE REQUIRED TO:
• Complete this form.
• Provide complete documentation of the disability. See requirements below. If you
don’t have your documentation, obtain it from your school, licensed psychologist or physician.
• Email this form, along with the documentation to: CSDoffice@ncc.edu
Any items that are checked must be supported by documentation or they will not be provided.
THIS INCLUDES THE PLACEMENT TEST. Upon review, we will contact you regarding accommodations.
I am requesting:
Reader (tape recorder or computer)
___ Extended Time
___ Enlarged computer screen/printed copy
___ CCTV (closed circuit TV)
___ Sign Language Interpreter
___ Other _______________________
Student’s Name: __________________________________ NCC ID #: N00______________________
Entering Semester: Fall _____ Spring ____ Summer ____
(year) (year) (year)
Address: _______________________________________________________________________ _
(Number and Street) (Apt. #)
(City) (State) (Zip Code)
Phone Number: Home: ______________________ Cell: _______________________________
Student Signature ___________________________________ Date__________________________
WHERE SUCCESS STARTS...AND CONTINUES 7/30/18
Nassau Community College is a unit of The State University of New York sponsored by Nassau County
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