Alternate Format Book Request Form Student Support Office of ACCESSibility Information for Current Students Alternate Format Book Request Form Alternate Format Book Request Form Please fill in a valid value for all required fields Please ensure all values are in a proper format. Are you sure you want to leave this form and resume later? Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form. Save and Resume Later Save and get link You must upload one of the following file types for the selected field: There was an error displaying the form. Please copy and paste the embed code again. Apply Discount You saved with code Submit Form Submitting Validating There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue. Please check the field: Fields 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: * https://www.formstack.com/forms/images/2/calendar.png Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 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* [clear] Use your mouse or finger to draw your signature above Date/Time https://www.formstack.com/forms/images/2/calendar.png Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 Previous← Next→ Formstack Online Forms Enter your save and resume password Cancel Confirm
