Lehman College Office of Student Disability Services ALTERNATE FORMAT TEXTBOOK REQUEST FORM Date: ____/____/_________ Student Name: ______________________________________ Student Contact #: ___________________ Email:____________________________ Course: ____________________ Instructor: ______________________________ Book Title: ___________________________________________________________ ___________________________________________________________ Author(s):____________________________________________________________ ____________________________________________________________ Publisher: ___________________________________________________________ Copyright Date: ____/____/__________ Edition: ________________________ 10 Digit ISBN#: ____________________________ Where did you buy book? ____________________________ Cost: ____________ *In order to fulfill your request, it is mandatory that you purchase or rent the requested book and provide the Office a copy of the receipt.* Format Request: Select one of these formats. Audio File Accessible Structured PDF Microsoft Word Audio (Daisy/Learning Ally) CD Learning Ally Formerly known as RFB & D Order Date: ______/______/________ Ordered from: _______________________________ Phone or email: ________________________ Delivery Date: ____/_____/_________ Comment: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Updated -10/30/2011 M. Santander For Office Use Only: