ALTERNATE TEXT REQUEST FORM

Please complete this form if you are eligible to receive books in alternative format. If requesting more than 4 books, please complete two alternative text request forms.

Name Name First Last
Email
Book 1

Please fill in information pertaining to the first book you are requestioning.
Book Title:
Full Name of Author(s):
Edition and Copyright Year:
ISBN 13 (example: 9780000000000):
Publisher:
Course Name and Number:
Proof of Purchase (Receipt)? (Some publishers require books to be purchased new)

Proof of Purchase (Receipt)? (Some publishers require books to be purchased new) Purchased new book Purchased used book Rented book
Please upload a copy of your receipt to show proof of purchase.

Attach Files
Format preferred:

Format preferred: Screen Readable Document (PDF or DOC) PDF (for large print) audiobook Other Other
Book 2

Please fill in information pertaining to the first book you are requestioning.
Book Title:
Full Name of Author(s):
Edition and Copyright Year:
ISBN 13 (example: 9780000000000):
Publisher:
Course Name and Number:
Proof of Purchase (Receipt)? (Some publishers require books to be purchased new)

Proof of Purchase (Receipt)? (Some publishers require books to be purchased new) Purchased new book Purchased used book Rented book
Please upload a copy of your receipt to show proof of purchase.

Attach Files
Format preferred:

Format preferred: Screen Readable Document (PDF or DOC) PDF (for large print) audiobook Other Other
Book 3

Please fill in information pertaining to the first book you are requestioning.
Book Title:
Full Name of Author(s):
Edition and Copyright Year:
ISBN 13 (example: 9780000000000):
Publisher:
Course Name and Number:
Proof of Purchase (Receipt)? (Some publishers require books to be purchased new)

Proof of Purchase (Receipt)? (Some publishers require books to be purchased new) Purchased new book Purchased used book Rented book
Please upload a copy of your receipt to show proof of purchase.

Attach Files
Format preferred:

Format preferred: Screen Readable Document (PDF or DOC) PDF (for large print) audiobook Other Other
Book 4

Please fill in information pertaining to the first book you are requestioning.
Book Title:
Full Name of Author(s):
Edition and Copyright Year:
ISBN 13 (example: 9780000000000):
Publisher:
Course Name and Number:
Proof of Purchase (Receipt)? (Some publishers require books to be purchased new)

Proof of Purchase (Receipt)? (Some publishers require books to be purchased new) Purchased new book Purchased used book Rented book
Please upload a copy of your receipt to show proof of purchase.

Attach Files
Format preferred:

Format preferred: Screen Readable Document (PDF or DOC) PDF (for large print) audiobook Other Other
I have read, understood and agree to the following (please check each statement):

I have read, understood and agree to the following (please check each statement): I understand it is my responsibility to notify AccessibleNU (ANU) every semester if I want to request alternate formats and will fill out and sign an Alternative Text Request Form for the books that I am requesting. Only required readings/books will be provided. I agree to notify ANU if there are any changes in my schedule or my need for alternate text has changed, e.g., dropped the course, a change in the syllabus, etc. I agree to make my request for materials in alternate media when I register for classes or as soon as possible thereafter. It is advisable to allow at least four weeks prior to your need for the electronic text. I have purchased a new physical copy of the text and will provide a copy of the receipt if necessary. Most publishers will only provide alternate format for textbooks purchased new. I understand the contents of all books are protected under copyright law. Copying, sharing or redistributing books in any form to any person is strictly prohibited by law and is a violation of publishers' rights. Violators face possible civil or criminal penalties. I agree and understand all the terms and conditions on this form
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ALTERNATE TEXT REQUEST FORM

ALTERNATE TEXT REQUEST FORM

Book 1

Book 2

Book 3

Book 4