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Alternative Format / E Text Book Request Form

Alternative Format / E Text Book Request Form



By submitting this form you the student, are agreeing to an electronic signature and have requested material (“the text”) in an alternative format. The student agrees to all of the following:

1. The alternative format is for use only by the student in connection with a course in which he/she is registered. The course information is provided above.

2. The text is a required text for the course.

3. The student has a disability that prevents him/her from using only the print version of the text. Documentation is on file with the student’s coordinator about this disability.

4. The text has been purchased by the student, and will be kept for the length of time the student uses the alternative format.

5. The student will use the alternative format in a specialized format solely for his or her own educational purposes.

6. The student will not copy, duplicate, or distribute the alternative format for use by others.

7. The Office of Disability Resources may need to disclose the student’s name and contact information upon request of the publisher.

This request is made in accordance with the Copyright Revisions Act of 1976, as amended (17 U.S.C. Sec. 101 et Seq.).


Student's Name

Delta E-Mail Address

 
Phone Number
Student ID Number
Request Date

Semester


Book 1
Course and Section
Title
ISBN Number
Author
Publisher


Book 2
Course and Section
Title
ISBN Number
Author
Publisher


Book 3
Course and Section
Title
ISBN Number
Author
Publisher


Book 4
Course and Section
Title
ISBN Number
Author
Publisher

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