Request for textbook in Alternate Format
Student name: ____________________________________________________________
Date: __________________________
Email/Phone #_____________________________________________________________
Semester: ______________________
Please submit the following information for each textbook requested in alternate format. Obtaining your textbooks in alternate format is time
intensive and can take more that 6 weeks to put in place. Please turn in this form as soon as possible in person, via email to
lillian.liebenthal@conncoll.edu, or via fax at 860-439-2003.
Note: Your receipt for the purchase of the book MUST be submitted to the Student Disability Services office with the request for alternate format.
Title
Author
Publisher/
Edition
th
Ex. Pearson/5 edition
ISBN#
13 or 10digits
Ex.978-0812297814 or
0812219783
Copyright/
Number of
pages
Course/
Instructor
Ex. BIO 106-1/Jones, Matthew
Before you purchase the hardcover/paperback version of your books, please check to see if the CD/ebook version is available.
Note: An individual membership for free ebooks is available at www.bookshare.org.
Requesting a course syllabus (if available) from your professor is helpful in determining your need for alternate format.
Please use additional forms as necessary.
Date OSDS received the request _______________
4/12