Document Conversion Request Form

Name:  ________________   Phone #: __________________

Semester:  _____________   Date: _________            Time: _________

 

Requested Format:

Braille: ___ E-Text (CD-R): ____ Large Print:  Style: ________ Font: ___ Other: ___

Item(s) Submitted: (check the box for the particular item that is being requested to be re-formatted)        

Book     Syllabus         Test         Notes         Handout 

 

Items Completed:

#	Item	Student Contacted	Professor Contacted	Picked Up By	Pick Up Date
1		Y              N	Y              N
2		Y              N	Y              N
3		Y              N	Y              N

 

You must be pre-approved to receive this accommodation prior to filling out this request.  Please see the Director if you have any questions.  You are required to submit a copy of the item needing converting at time of the request.  Textbooks will be unbound and run through a fast-speed scanner.  The textbook will be returned to you unbound.

Work orders are done on a first-come, first-served basis.  We will make every effort to provide the alternative format

to you within 2 business days.

 

I agree to adhere to copyright laws set forth on textbook conversions.  I also agree to use the CD for my own  personal needs.  I will not share any of the information contained in this CD with others.  I understand the      conditions outlined in the paragraph above and agree to these terms.

 

    ___________________________________________                              __________________________

    Signature                                                                                                    Date                            08/02