Alternate Format Request Form

Name*
First Last
Date
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Phone
Course Code and Name
Date for Receipt of Materials Needed
A. Types of Materials Being requested:
- Book
- Article
- Course Pack
- Research Material
- Other
B. Specified Request
Specify title, author, date of publication, etc.
B. Please attach a copy of your course syllabus.
Max. file size: 128 MB.
C.Please provide any details about upcoming reading assignments we need to consider while fulfilling your request.
D. Optionally, you can upload a receipt, rental slip or other item which demonstrates possession of the requested material in case it is required by the publisher.
Max. file size: 128 MB.
I verify possession of the academic materials being requested and can provide Assistive Technology Services with proof of possession should it be necessary to fulfill my request for alternative format materials.
I verify the following