Fillable Alternative Media Requests Form Back

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Alternative Media Requests Form Back

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Country of origin: US
File type: PDF

U.S.A. forms for California State University Channel Islands

BROWSE CALIFORNIA STATE UNIVERSITY CHANNEL ISLANDS FORMS

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Copyright Notice: By initialing this Alternate Media Material Request form when picking up any electronic instructional material, the student is agreeing to use the electronic copy of
the printed material solely for his/her own educational purposes, and that he/she will not copy or duplicate the electronic instructional material for use by others.
Initials
-up Date
Staff Initials
Initials
Staff Initials
-up Date
Staff Initials
-up Date
Initials
Copyright Notice: By initialing this Alternate Media Material Request form when picking up any electronic instructional material, the student is agreeing to use the electronic copy of
the printed material solely for his/her own educational purposes, and that he/she will not copy or duplicate the electronic instructional material for use by others.
Alternate Media Material Request Fields marked with * are required
PART 1 - Material Information PART 2 - *Alternate Format Requested:
Book Online rial Mate Handouts Other Audio (MP3) Kurzweil
*Title PDF Text
Author )(s Optional:
Large Print @ 129%
Text
Copyright Date Edition (Enlarged)
Large Print @ 155%
Publisher
Literary Braille
ISBN Braille
Nemeth Braille
*Course Number *Section
(Ex: HIST 211) Tactile graphics
*Instructor Other:
PART 3 Ch t ( ) I f ti
PART 3 - Chapter(s) Information
*Select chapters requested or a All Bll book ook12345678910
Date Completed
FOR STAFF USE
Pick
ONLY
Student
Select chapters request 1ed 1 12 13 14 15 16 17 18 19 20 21
Date Completed
FOR STAFF USE
Pick
ONLY
Student
Select chapters request 2ed 2 23 24 25 26 27 28 29 30 31 32
Date Completed
FOR STAFF USE
Pick
ONLY
Student
Student t r rati e
has submit ed documentation of their course egist on and proof of t xtbook
gp p
purchase: Yes Other:
Copyright Notice: By initialing this Alternate Media Material Request form when picking up any electronic instructional material, the student is agreeing to use the electronic copy of
the printed material solely for his/her own educational purposes, and that he/she will not copy or duplicate the electronic instructional material for use by others.
FOR STAFF USE
ONLY
FOR STAFF USE
ONLY
FOR STAFF USE
ONLY
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Alternative Media Requests Form Back

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Completed 11 February 2020

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