E-text/Recorded Text Request Form
Disability Support Services
Southern Adventist University
Student Name (print/type)___________________________________ Phone______________________
Semester/Session needed: Fall _____ Winter _____ Summer (1-3) _____ Year ____________
Book Title & subtitle___________________________________________________________________
Author(s) full name(s) __________________________________________________________________
Copyright Date__________________ ISBN________________________________________________
_
Edition_____________ Publisher________________________________________________________
Course Title_______________________________________________ Course # __________________
Instructor/Professor ___________________________________________________________________
Text was purchased from _________________________________on _______________ for $________
Request:
I prefer t
he following format(s) (check all that apply & indicate order of preference):
Word Documents (to be read with text-to-speech or screen reader)
Wi
ndows for PC
Macintosh
PDF (to be read with text-to-speech or screen reader)
Audio file
Other: __________________________________________________________________
Comments:___________________________________________________________________________
Student Signature: _________________________________________ Date: _____________________
For Office Use Only:
Date of
Request
Date Ordered
from
Publisher.
Staff initials
Date
Received/
Staff
initials
# of
CDs
Date Student
Contacted for
Pickup/ Staff
initials
Date of
Student
Pickup/St.
initials
Date CDs
Returned by
Student/
Staff initials
Number
of CDs
Returned
Distribution Agreement Signed? ___ Yes ___ No
Request received by DSS Staff ________________________________________________________
Printed name Initials Date
Rev. 10/14
To be completed in the presence of DSS Staff:
I have read and understand the terms and conditions outlined in the Electronic Text Distribution
Agreement.