Disability Services
P.O. Box 3300 Somerville, New Jersey 08876-1265
Phone: 908-526-1200 x8921 Fax: 908-526-3494
rnative Text Request Form
Name: RVCC ID#: _G______
E-mail: Phone:
Course Number & Title: Instructor:
Title of Text:
Author: Publisher:
ISBN#: Copyright year:
Semester: Fall Spring Summer
Format Preferred:
MS Word PDF Text document
consideration of the provision of textbooks and course materials in alternative text formats, Student
acknowledges and agrees to the following:
I agree to research the availability of this alternative text on websites including: Bookshare.org,
Learningally.org, and other commercially available options.
I understand that I must document a qualifying disability.
I understand that I must own a physical copy of all materials requested in alternative format.
I understand that I must be currently registered and enrolled in the particular class(es) f
or which I am
requesting alternatively formatted materials.
I agree not to copy or reproduce alternatively formatted materials, nor allow anyone else to do so.
I understand that I assume all risk for damage to or loss of materials while they are signed out to me.
I understand that failure to adhere to these regulations may b
e considered a violation of federal
and/or state laws and may result in civil or criminal prosecution, payment of fines or other monies to
the copyright holder, and/or incarceration.
I agree to submit my request(s) in a timely manner. I understand that pr
ocurement of alternative texts
may take up to 6 weeks. To ensure availability of materials, I agree to submit my request(s) as soon as
my textbook information is available. I understand DS will diligently work to honor all requests, but
late requests may not be fulfilled by the time materials are needed.
Before receipt of materials, this agreement shall be signed by the student and the designated college official and
kept on file.
I have read and understand the policies and procedures outlined above and agree to comply.
Student RVCC ID# Date
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