Alternative Format Services

Request Form

Media Center/Arizona Instructional Resource Center

1235 E. Harmont Drive, Phoenix, AZ 85020

Phone:602.678.5810 or 5816 Fax:602.678.5811

www.SeeItOurway.org

Please fill out one Alternative Format Services Request form per book per student. For Braille/large print/e-file requests, we require a hard copy of the print textbook/book. Please Note: Books must be scanned for production, so it will be cut.

BEFORE YOU START THE FORM PLEASE READ..........

Please fill out the Certification of Eligibility/Copyright Use Consent form at (click on link for form) http://webzoom.freewebs.com/fbcatservices/Eligibility%20&%20Copyright%20Use.pdf which must be signed and can be fax in.

If requesting a textbook with a copyright year of 2006 or newer, a NIMAS request form must also be fill out and signed at http://webzoom.freewebs.com/fbcatservices/NIMAS%20-%20%20Request%20Form.doc for each textbook and this can be fax in also.

* Name of person filling out this request:

Renewal

If Checked Please fill in Accession Number, which is on Textbook property label or the spine.

Accession Number

* Today's Date:

* Textbook/Rec Book Format

Date Needed by:

* Semester

* Student Name:

* Grade

* School District

District PO Number

* School Name:

* Student's TVI Name:

* Requestor's Phone Number:

* Requestor's Email Address:

* Requestor's Email Address Verfication:

Textbook/Rec Book Infomation

* Title of Textbook/Rec Book:

* ISBN of Textbook/Rec Book:

Author of Textbook/Rec Book:

* Publisher of Textbook/Rec Book:

* Copyright of Textbook/Rec Book:

* Number of Physical Print Pages:

Braille Production Preferences

Braille Format:

Pagination:

Line Spacing:

Large Print Production Preferences

Paper Color:

Original Bound:

Comments:

E-File/E-books Production Preferences

What device to be used?

Visual Access:

Delivery Preference

Will be picked up by:

Product will be mailed to (Enter full address, no P.O. Boxes):

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