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Alternative Format Textbook Request
Minnesota State University Moorhead
Disability Services (DS)

Text in alternate format is provided to students with print disabilities who are registered with Disability Services and have been determined eligible for this accommodation.

Disability Services will not process your request to obtain this text in alternate format until you have:

Complete and submit this form in its entirety

**Complete one form for each book you need.**

Name:
Telephone #:
E-Mail Address:
Semester/Year:

Complete Textbook Title:
Author(s):
Textbook Publisher:
Year Published:                      Edition Number:
ISBN #:

Class Number: Course Title: ex: Music Theory
Course ID#:

Instructor’s Name:

If Disability Services needs to record this text for me, I would prefer:
Cassette
MP3 Format

If I check out any Adaptive Equipment from Disability Services, I will return it within 2 weeks of the end of the semester.

I will replace any broken or damaged adaptive equipment that I checked out from Disability Services.

I certify that I have purchased and am the legal owner of the textbook I am requesting above. I understand that if I share any files/tapes received from Disability Services with other students that I may be prosecuted for copyright infringement and many lose the right to obtain texts in alternative format.

If class is dropped, it is your responsibility to notify Disability Services as soon as possible..

I have read the above and agree to follow the policies.

If you are unable to complete this form due to your disability, please contact Greg Toutges, Coordinator of Disability Services at 477-2131 and assistance will be arranged.

© 2003 Minnesota State University Moorhead
1104 7th Ave S.
Moorhead, MN 56563
1.800.593.7246
For TTY communication, contact the Minnesota Relay Service at 1-800-627-3529.
an equal opportunity educator and employer

Contact toutges@mnstate.edu
Last Update Date: 08/08/08