Please complete a SEPARATE form for EACH REQUEST to be submitted. Each textbook, workbook, course reading packet, etc. will require a separate Alternate Format Request to be submitted.
Alternate or Cell Phone:
**Title of Material:
Choose the type of material you are requesting we convert to another format.
If you select the Other option, input the other material type in the field to the right. For example, Power Point presentation, overhead projection slides, digital file on CD, etc.
COMMENTS OR SPECIAL INSTRUCTIONS
Type any additional comments or special instructions in this field. Comments or special instructions can be up to 500 characters in length. If you feel there are additional details that might help ensure you receive your materials in the requested alternate format in a timely manner, please include them here. Your comments can help our staff serve you better.
*Enter the number shown in the box below (We use this tool to help stop spammers):
You will also receive a copy of your submitted Alternate Request form in your email inbox. Please print or save this copy as your submission receipt.
Click the Submit button to send your completed Alternate Format Request form. If your Alternate Request form has been successfully submitted, you should be presented with another screen/webpage thanking you for your submission.
The Clear Form button will clear all the information from the Alternate Request form. Do not use it unless you intend to clear all the information from the Alternate Format Request form without submitting it.
If you have questions or would like additional assistance with completing the Alternate Request form, please contact Vicki Fox, Disability Services Coordinator and Alternate Format Services Specialist at (906635-2355 or firstname.lastname@example.org.