Request for Electronic Version of a Textbook

Verification of textbook purchase is required. Please scan your receipt and attach with this form. If you cannot scan the receipt, please submit this form and then bring the hard copy receipt to the Accessibility Resources Center office located in Sheffield Hall.

University of New Haven Campus (please check all that apply):

University of New Haven Campus (please check all that apply): West Haven, CT New London, CT Old Lyme, CT Prato, Italy San Francisco, CA Albuquerque, NM
Semester

Semester Fall Spring Summer
Date: Date: / MM / DD YYYY
Student name: Student name: First Last
Phone: Phone: - ### - ### ####
Residency:

Residency: On-campus Off-campus
Email
Book Information:
Author(s):
Title:
Edition:
Publisher:
Course Information:
Course number:
Course section:
Course title:
Instructor:
Disclaimer Terms and Conditions:

I have purchased the textbook listed above and am requesting that it be converted to an alternate format to make it accessible to me. I have attached a copy of my original receipt for verification of my purchase.

I understand that, if my book is not available in electronic format from the publisher or other sources, the book will be unbound (chopped) so that it can be scanned by the volume scanner. I am aware that this procedure may prevent my returning of the book to the bookstore for a refund. I understand that any alternative text, which may be supplied to me, is solely for my own educational purposes. I will not copy or distribute any such alternative text as it is a violation of the Copyright Revisions Act of 1976, as amended (17 U.S.C. Sec. 101 et seq.). I understand that failure to abide by this agreement may constitute a violation of the Student Code of Conduct, and/or the university ARC policy regarding the responsible use of ARC services and I understand that a violation of any university policy, including improper distribution of electronic text, may result in disciplinary action.
Student Signature:

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Technical Information:
Desired format:

Desired format: Microsoft Word Kurzweil 3000 Other Other
Computer Platform:

Computer Platform: Windows Mac
Storage Format:

Storage Format: CD-Rom E-mail Other Other
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Request for Electronic Version of a Textbook

Request for Electronic Version of a Textbook

Book Information:

Course Information:

Disclaimer Terms and Conditions:

Technical Information: