DISABILITY RESOURCE CENTER
240K Student Center
Phone: (734) 487-2470 Fax: (734) 483-6515
Email: drc@emich.edu
ALTERNATIVE FORMAT/ E-TEXT (ELECTRONIC TEXTBOOK) REQUEST FORM
Books/E-Text requests are processed in the order they are received. The process can take from 2-8 weeks.
Please communicate with the Alt. Media Coordinator at sa_alternativemedia@emich.edu
if you need further assistance.
Student Name
Local Phone # (
E-ID _______________________________________
)
Email _____
DRC Advisor ___ _______________________________
Instructor
Course ______________________ Section _________
Full Title of Text
ISBN (10/13 digits)________________________________
Cost of text $
Authors ________________________________________
Publisher ____________________________________
Preferred Format (circle all that apply)
PDF
MS WORD
Rich Text Format
HTML
Audio
Please Note: We cannot guarantee your book will be in the format you request. The publisher determines what types
of files we receive. However, we will attempt to convert your e-text to the preferred format if possible.
The student whose signature appears below has requested material (“the text”) in an alternative format, and agrees to all of the following:
1.
2.
3.
4.
5.
6.
7.
8.
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.
The student is to provide copies of the book receipt.
The book is a required text for the course.
The student has a disability that prevents him/her from using the print version of the text. Documentation is on file in the DRC office.
The book has been purchased by the student, and will be kept for the length of time the student uses the alternative format.
The student will use the alternative format in a specialized format solely for his or her own educational purposes.
The student will not copy or duplicate the alternative format for use by others.
The DRC 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.).
Signature:______________________________________________ Date:__________________________
Entered into Database
Date of 1st Request to Publisher:
Date of 1st Response from Publisher:
Copy of Receipt:
___ Yes ___ No
Confirmation ID:
Confirmation Date:
DRC Initials:
Date of 2nd Follow-Up Letter:
Comments:
Student Signature for Pickup or Cancellation of Request
Signature:______________________________________________ Date:__________________________
Pickup
Pickup
Signature:______________________________________________ Date:__________________________
Canceled class and request
REVISED 8-2014
Canceled class and request