Fillable Etextrequestform (Southern College)

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Etextrequestform (Southern College)

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The Etextrequestform (Southern College) form is 1 page long and contains:

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  • 13 check-boxes
  • 17 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Southern College

BROWSE SOUTHERN COLLEGE FORMS

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E-text/Recorded Text Request Form
Disability Support Services
Southern Adventist University
Student Name (print/type)___________________________________ Phone______________________
Semester/Session needed: Fall _____ Winter _____ Summer (1-3) _____ Year ____________
Book Title & subtitle___________________________________________________________________
Author(s) full name(s) __________________________________________________________________
Copyright Date__________________ ISBN________________________________________________
_
Edition_____________ Publisher________________________________________________________
Course Title_______________________________________________ Course # __________________
Instructor/Professor ___________________________________________________________________
Text was purchased from _________________________________on _______________ for $________
Request:
I prefer t
he following format(s) (check all that apply & indicate order of preference):
□
Word Documents (to be read with text-to-speech or screen reader)
□ Wi
ndows for PC
□ Macintosh
□ PDF (to be read with text-to-speech or screen reader)
□ Audio file
□ Other: __________________________________________________________________
Comments:___________________________________________________________________________
Student Signature: _________________________________________ Date: _____________________
For Office Use Only:
Date of
Request
Date Ordered
from
Publisher.
Staff initials
Date
Received/
Staff
initials
# of
CDs
Date Student
Contacted for
Pickup/ Staff
initials
Date of
Student
Pickup/St.
initials
Date CDs
Returned by
Student/
Staff initials
Number
of CDs
Returned
Distribution Agreement Signed? ___ Yes ___ No
Request received by DSS Staff ________________________________________________________
Printed name Initials Date
Rev. 10/14
To be completed in the presence of DSS Staff:
I have read and understand the terms and conditions outlined in the Electronic Text Distribution
Agreement.
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Etextrequestform (Southern College)

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Completed 24 July 2020

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