University of Montana
Print to Alternative Format Conversion Request Form
As a University of Montana-Missoula student with a print disability, I request that IT Central convert the
title below to an electronic format, which is accessible to me and for my personal educational use only.
I certify that I have purchased this book in print and understand that the information I provide on this
form may be submitted to the book publisher or the publisher s authori ed representative/distributor.
I understand that the Alternative Formats Coordinator will send my book, in an electronic file, to my
official UM EMAIL ADDRESS when the conversion of my book is finished.
Signature:
Date:
Student Name:
Student Phone:
Official UM Student Email:
Student ID:
DSS Coordinator:
Year in School (Fr., So., Jr., Sr.,
Birthdate
rad. Please provide if using Bookshare):
rad., Post
Please provide if using Bookshare
Book Title:
Authors/Editors:
Edition:
ISBN-13#:
Publisher:
Instructor:
Course Title:
Is this a Custom UM Edition? (Check one)
No
Yes
U
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Physical Copy
Sales Receipt
Authorization Initials
Assistive Technology Coordinator, check the appropriate format
1.
2.
3.
4.
5.
6.
Accessible (text-based) PDF file.
Plain text and Rich Text Format (*.txt & *.RTF) files.
Bookshare (Birthdate and Present Year in School are Require for Account Setup)
Learning Ally
DAISY Digital Talking Book.
Other, Specify
January 2016