Document Conversion Request Form

 

Name: _____________________ Banner ID: _____________ 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□

Number	Course Name & #	Professor	Book Information	Handout Information
1			Title	Title
			Author
2			Title	Title
			ISBN#
			Author
			Year
3
			Title	Title
			Author
			Year

 

Items Completed:

 

Number	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 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 this 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: ______________

                                                                                                                                                                                    01/09