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<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Strict//EN" <div id="maincontent"> <h2>Alternate Media Request Form</h2> <div id="formbox"> <form id="aform" method="post" action="media_form.asp" onsubmit="return validate(aform, val_order);"> <input type="hidden" name="Action" value="SendEmail"> <fieldset> <legend>General Information</legend> <label class="label" for="todaysdate">Today's Date <input class="formw" type="text" size="30" maxlength="256" name="todaysdate" id="todaysdate" /></label> <label class="label" for="requestorname">Name <em>(First &amp; Last, <strong>Required</strong>)</em> <input class="formw" type="text" size="30" maxlength="256" name="requestorname" id="requestorname" value="" /></label> <label class="label" for="SID">Student ID <input class="formw" type="text" size="30" maxlength="11" name="SID" id="SID" value="" /></label> <BR> <label class="label" for="email"> Email <em>(<strong>Required</strong>)</em> <input class="formw" size="50" maxlength="50" name="email" id="email" value="" /> </label> <label class="label" for="phone"> Phone <input class="formw" type="text" size="30" maxlength="25" name="phone" id="phone" value="" /></label> </fieldset> <fieldset class="list"> <legend class="radio">Contact Preference</legend> The best way to contact me is: <label class="inline" for="contactpref_phone"><input type="radio" class="clean_input" name="contactpref" id="contactpref_phone" value="phone" />Phone </label> <label class="inline" for="contactpref_no"><input type="radio" class="clean_input" name="contactpref" id="contactpref_no" value="email" /> Email</label> </fieldset><BR> <fieldset> <legend>Textbook Information</legend><BR> <table class="altmedia"> <tbody><caption>Please complete the following for each requested textbook/class material for which you will need alternative media. <strong> </strong></caption> <tr> <th>Class Name and Number</th> <th>ISBN #</th> <th>Book Title</th> <th>Edition</th> </tr> <tr> <td><label class="hidden" for="classname1">Class Name and Number (1)</label><input class="nomdata" type="text" size="25" maxlength="35" name="classname1" id="classname1" value="" /></td> <td><label class="hidden" for="isbn1">ISBN (1)</label><input class="numdata" type="text" size="13" maxlength="13" name="isbn1" id="isbn1" value="" /></td> <td><label class="hidden" for="booktitle1">Book Title(1)</label><input class="nomdata" type="text" size="40" maxlength="40" name="booktitle1" id="booktitle1" value="" /></td> <td><label class="hidden" for="edition1">Edition(1)</label><input class="numdata" type="text" size="4" maxlength="4" name="edition1" id="edition1" value="" /></td> </tr> <td><label class="hidden" for="classname2">Class Name and Number (2)</label><input class="nomdata" type="text" size="25" maxlength="35" name="classname2" id="classname2" value="" /></td> <td><label class="hidden" for="isbn2">ISBN (2)</label><input class="numdata" type="text" size="13" maxlength="13" name="isbn2" id="isbn2" value="" /></td> <td><label class="hidden" for="booktitle2">Book Title(2)</label><input class="nomdata" type="text" size="40" maxlength="40" name="booktitle2" id="booktitle2" value="" /></td> <td><label class="hidden" for="edition1">Edition(2)</label><input class="numdata" type="text" size="4" maxlength="4" name="edition2" id="edition2" value="" /></td> </tr> <td><label class="hidden" for="classname3">Class Name and Number (3)</label><input class="nomdata" type="text" size="25" maxlength="35" name="classname3" id="classname3" value="" /></td> <td><label class="hidden" for="isbn3">ISBN (3)</label><input class="numdata" type="text" size="13" maxlength="13" name="isbn3" id="isbn3" value="" /></td> <td><label class="hidden" for="booktitle3">Book Title(3)</label><input class="nomdata" type="text" size="40" maxlength="40" name="booktitle3" id="booktitle3" value="" /></td> <td><label class="hidden" for="edition3">Edition(3)</label><input class="numdata" type="text" size="4" maxlength="4" name="edition3" id="edition3" value="" /></td> </tr> <td><label class="hidden" for="classname4">Class Name and Number (4)</label><input class="nomdata" type="text" size="25" maxlength="35" name="classname4" id="classname4" value="" /></td> <td><label class="hidden" for="isbn4">ISBN (4)</label><input class="numdata" type="text" size="13" maxlength="13" name="isbn4" id="isbn4" value="" /></td> <td><label class="hidden" for="booktitle4">Book Title(4)</label><input class="nomdata" type="text" size="40" maxlength="40" name="booktitle4" id="booktitle4" value="" /></td> <td><label class="hidden" for="edition4">Edition(4)</label><input class="numdata" type="text" size="4" maxlength="4" name="edition4" id="edition4" value="" /></td> </tr> <td><label class="hidden" for="classname5">Class Name and Number (5)</label><input class="nomdata" type="text" size="25" maxlength="35" name="classname5" id="classname5" value="" /></td> <td><label class="hidden" for="isbn5">ISBN (5)</label><input class="numdata" type="text" size="13" maxlength="13" name="isbn5" id="isbn5" value="" /></td> <td><label class="hidden" for="booktitle5">Book Title(5)</label><input class="nomdata" type="text" size="40" maxlength="40" name="booktitle5" id="booktitle5" value="" /></td> <td><label class="hidden" for="edition5">Edition(5)</label><input class="numdata" type="text" size="4" maxlength="4" name="edition5" id="edition5" value="" /></td> </tr> <td><label class="hidden" for="classname6">Class Name and Number (6)</label><input class="nomdata" type="text" size="25" maxlength="35" name="classname6" id="classname6" value="" /></td> <td><label class="hidden" for="isbn6">ISBN (6)</label><input class="numdata" type="text" size="13" maxlength="13" name="isbn6" id="isbn6" value="" /></td> <td><label class="hidden" for="booktitle6">Book Title(6)</label><input class="nomdata" type="text" size="40" maxlength="40" name="booktitle6" id="booktitle6" value="" /></td> <td><label class="hidden" for="edition6">Edition(6)</label><input class="numdata" type="text" size="4" maxlength="4" name="edition6" id="edition6" value="" /></td> </tr> <td><label class="hidden" for="classname4">Class Name and Number (4)</label><input class="nomdata" type="text" size="25" maxlength="35" name </tbody> </table> </fieldset> <fieldset class="list"> <legend>Additional Textbook Information</legend> <label class="label" for="mediainfo">Are there specific books or classroom materials you know you <strong>do</strong> or <strong>do not</strong> need? Or is there other information that you can provide that will help us in preparing your class materials? Please indicate that here: <textarea name="mediainfo" cols="68" rows="2" id="mediainfo" > </textarea></label> <fieldset class="subset"> <legend class="radio">File Format Preference (REQUIRED)</legend> Please choose a specific format, you may choose only two:</p> <label class="label" for="text"> <input type="checkbox" class="clean_input" name="Kurzweil" id="Kurzweil" value="true" />Kurzweil</label> <label class="label" for="rtf"> <input name="rtf" type="checkbox" class="clean_input" id="rtf" value="true" />RTF (Rich Text Format)</label> <label class="label" for="doc"> <input name="doc" type="checkbox" class="clean_input" id="doc" value="true" />Word/DOC</label> <label class="label" for="pdf"> <input name="pdf" type="checkbox" class="clean_input" id="pdf" value="true" />PDF</label> <label class="label" for="mp3"> <input name="mp3" type="checkbox" class="clean_input" id="mp3" value="true" />MP3/Audio</label> <label class="label" for="mp3"> <input name="braillehardcopy" type="checkbox" class="clean_input" id="braillehardcopy" value="true" />Braille(hardcopy)</label> <input name="brailleelectronic" type="checkbox" class="clean_input" id="brailleelectronic" value="true" />Braille(Electronic)</label> <input name="largeprint" type="checkbox" class="clean_input" id="largeprint" value="true" />Large Print</label> </fieldset> <fieldset class="button"><input type="submit" class="button" value="Submit Form" name="Submit" id="Submit" /></fieldset> </form> </div> </div> </div> </div> <div id="catch"></div> <div id="footer"> <div id="footer_center"> <div id="address"> <p><strong><a href="http://www.butte.edu">Butte College</a></strong></p> </div> <p>Last updated on <script src="scripts/update.js" type="text/javascript"></script> </p> <noscript><p>(This displays date last modified and requires JavaScript to view.)</p></noscript> <div id="colophon"><p>Maintained by: <a href="mailto:dsps@butte.edu">Butte College DSPS</a></p> </div> </div> </div> </body></html>
