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Digital Text Request (students w/disabilities)

This form is for students enrolled with Disability Services who qualify for alternative text format.

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Your Information
 
First Name    Middle Name    Last Name    Suffix
     
Phone   College ID   E-mail
   

 
Agreement
 
Copy of Receipt
 
Receipt
 

 
Textbook #1
 
Course Name & Number:
 
Instructor:
 
Title of Textbook:
 
Edition:
 
Copyright Date:
 
Author(s):
 
ISBN:
 
Publisher:
 
Please provide the last page number in the book.  
 

 
Textbook #2
 
Course Name & Number:
 
Instructor:
 
Title of Textbook:
 
Edition:
 
Copyright Date:
 
Author(s):
 
ISBN:
 
Publisher:
 
Please provide the last page number in the book.  
 

 
Textbook #3
 
Course Name & Number:
 
Instructor:
 
Title of Textbook:
 
Edition:
 
Copyright Date:
 
Author(s):
 
ISBN:
 
Publisher:
 
Please provide the last page number in the book.  
 

 
Textbook #4
 
Course Name & Number:
 
Instructor:
 
Title of Textbook:
 
Edition:
 
Copyright Date:
 
Author(s):
 
ISBN:
 
Publisher:
 
Please provide the last page number in the book.  
 

 
Textbook #5
 
Course Name & Number:
 
Instructor:
 
Title of Textbook:
 
Edition:
 
Copyright Date:
 
Author(s):
 
ISBN:
 
Publisher:
 
Please provide the last page number in the book.  
 

 
Textbook #6
 
Course Name & Number:
 
Instructor:
 
Title of Textbook:
 
Edition:
 
Copyright Date:
 
Author(s):
 
ISBN:
 
Publisher:
 
Please provide the last page number in the book.