All information must be filled in completely or we will send this form back to you. 

Student Information

Full Name:

E-Mail Address:

Phone Number:

Course Information


Course Name:

Course Number (e.g., Psych 101):

Instructor Name:

Material Requested

Book Title:

Book Publisher:




Date of textbook purchase:          Purchase Price:

Location of textbook purchase:

Type of file requested:

PC ____ Mac ____

Adobe Acrobat ____Microsoft Word ____


Do you agree to the following terms:  Yes ____  No ____

1)  That you have purchased the book that you are requesting an alternative format for (proof of purchase must be submitted to the SDS office during the first week of classes to be kept on file).

2)  That you will not reproduce your alternative format materials in any way.


When you have completed this form, please save it, attach it to an email and return to: and   

You can attach as many forms as you want to one email, but please be sure to fill out 1 form for each book requested.

Any questions give us a call at 607-436-2137