Alternate Format Book Request Form

Students who have the approved accommodation of receiving their books in alternative formats should complete this form. It can take up to 2 weeks for our office to fulfill this request. It is imperative that the information provided is correct and submitted in a timely manner. With this form, you must also submit a receipt for the hard copy of the book as a proof of purchase. We cannot begin processing your requests for books without receipts. If you have any questions, please don't hesitate to contact the ACCESSibility Office at accessibility@mercy.edu .

Description Area

General Information

Full Name *

Preferred Email *

Best Contact Number *

Semester*

Fall Spring Summer

Year: *

CWID *

Book Information #1

Full Book Title *

ISBN *

Author’s Name *

Edition *

Publisher *

Upload Receipt *

No File Chosen

File uploads may not work on some mobile devices.

Do you need to make a request for another book? *

Yes No

Book Information #2

Full Book Title*

ISBN*

Author’s Name*

Edition*

Publisher*

Upload Receipt*

No File Chosen

File uploads may not work on some mobile devices.

It is permissible to upload the same receipt that you used for the previous book if the books are part of the same puchase.

Do you need to make a request for another book? *

Yes No

Book Information #3

Full Book Title*

ISBN*

Author’s Name*

Edition*

Publisher*

Upload Receipt*

No File Chosen

File uploads may not work on some mobile devices.

It is permissible to upload the same receipt that you used for the previous book if the books are part of the same puchase.

Do you need to make a request for another book?*

Yes No

Book Information #4

Full Book Title*

ISBN*

Author’s Name*

Edition*

Publisher*

Upload Receipt*

No File Chosen

File uploads may not work on some mobile devices.

It is permissible to upload the same receipt that you used for the previous book if the books are part of the same puchase.

Do you need to make a request for another book?*

Yes No

Book Information #5

Full Book Title*

ISBN*

Author’s Name*

Edition*

Publisher*

Upload Receipt*

No File Chosen

File uploads may not work on some mobile devices.

It is permissible to upload the same receipt that you used for the previous book if the books are part of the same puchase.

Do you need to make a request for another book?*

Yes No

Book Information #6

Full Book Title*

ISBN*

Author’s Name*

Edition*

Publisher*

Upload Receipt*

No File Chosen

File uploads may not work on some mobile devices.

It is permissible to upload the same receipt that you used for the previous book if the books are part of the same puchase.

Do you need to make a request for another book?*

Yes No

Book Information #7

Full Book Title*

ISBN*

Author’s Name*

Edition*

Publisher*

Upload Receipt*

No File Chosen

File uploads may not work on some mobile devices.

It is permissible to upload the same receipt that you used for the previous book if the books are part of the same puchase.

Do you need to make a request for another book?*

Yes No

Book Information #8

Full Book Title*

ISBN*

Author’s Name*

Edition*

Publisher*

Upload Receipt*

No File Chosen

File uploads may not work on some mobile devices.

It is permissible to upload the same receipt that you used for the previous book if the books are part of the same puchase.

Do you need to make a request for another book? *

Yes No

Book Information #9

Full Book Title*

ISBN*

Author’s Name*

Edition*

Publisher*

Upload Receipt*

No File Chosen

File uploads may not work on some mobile devices.

It is permissible to upload the same receipt that you used for the previous book if the books are part of the same puchase.

Do you need to make a request for another book? - Copy*

Yes No

Book Information #10

Full Book Title*

ISBN*

Author’s Name*

Edition*

Publisher*

Upload Receipt*

No File Chosen

File uploads may not work on some mobile devices.

It is permissible to upload the same receipt that you used for the previous book if the books are part of the same puchase.

Do you need to make a request for another book?*

Yes No

Acknowledgement

*

I understand that the alternative format books that I receive are for use in connection with a course in which I am registered and that the sole use is for my own educational purposes. I agree that I will not copy or duplicate the file for use by others. I understand that I must provide a copy of the receipt for the book purchase by the end of the first week of classes. No books in alternate format can be released without proof of purchase on file. I also understand that I must return the alternate format at the end of the semester.

Signature*

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Date/Time

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