Digital Textbook Request Form — College of Education and Human Development

Your E-Mail Address

Comments Please enter any questions, comments, or additional information you have related to this request.

Textbook Information

Textbook Author's Last Name (if more than one author, provide last name for only first author listed)

Preferred file format for digital textbook being requested: (Choose one)

HTML (web page)
DAISY 2005 (talking book)
RTF WITH (text file with images)
RTF WITHOUT (text file without images)
WORD WITH (Word file with images)
WORD WITHOUT (Word file without images)
EPUB (for use with e-readers e.g., iPad)

Textbook Title (taken from the front cover or title page of the book)

Textbook Author's First Name (if more than one author, provide first name for only first author listed)

Textbook ISBN An ISBN will be either a 10-digit or 13-digit number. An ISBN can be found on either the back cover or the back of the title page. In cases where a book has both a 10-digit and 13-digit ISBN, you need only provide one of these ISBNs.

Contact Information

School Name and Mailing Address Provide name and mailing address of school where student is enrolled

Digital Rights Manager's Name (First Name Last Name)

Digital Rights Manager's E-Mail Address

Verification of Student Eligibility

I am requesting this digital textbook for a student whose qualifying disability is: (Choose one)

I have the complete NIMAS Eligibility Form on file, and it has been signed by the following "Competent Authority" for this disability type: (Choose one) REMEMBER: If you chose "Reading Disability" as the Disability Type in the previous item, the only acceptable "Competent Authority" to choose here is "Doctor of medicine".

A copy of the print version of the digital textbook requested has been purchased and is available for student use: (Choose one)

Yes
No
Don't Know/Not Sure

Please answer the following