REQUEST FOR ELECTRONIC TEXT FOR USE BY STUDENTS WITH DISABILITIES

To request an electronic text for a student with a verified disability, please print this form, make sure all sections are complete, and fax it to the University of Iowa Press at 319-335-2055. If available, your text should be delivered within two weeks.

BOOK INFORMATION
ISBN ________________________________________________________
TITLE ________________________________________________________
AUTHOR ________________________________________________________

COORDINATOR OF SERVICES / ADA COMPLIANCE OFFICIAL'S INFORMATION
Name ________________________________________________________
E-mail ________________________________________________________
Phone number ________________________________________________________
University, college, school, or campus _____________________________________________
Address ________________________________________________________
City, state, zip ________________________________________________________

ORDER DETAILS (Please select one of the following options.)
_____The student or institution has already purchased or will purchase the book and seeks a supplemental electronic text.
_____The student or institution has NOT purchased the book and will purchase an electronic text instead. The list price of the book will be billed to your institution. Please provide a purchase order number: ____________________________.

DELIVERY METHOD (Please select one of the following options.)
_____Ship a CD with this text to the address above. (No additional charge for shipping or media.)  
_____FTP the electronic text to the following FTP site. (No additional charge for shipping or media.)
FTP address: ____________________ user name: ______________
password: _________________________________

CERTIFICATION OF COORDINATOR OF SERVICES / ADA COMPLIANCE OFFICIAL

1. I certify that the student has a disability that prevents him or her from using standard instructional materials.
2. I certify that the book requested is for use by the student in connection with a course in which the student is registered at the university, college, school, or campus listed above.
3. I certify that the student has agreed that he or she will use the electronic copy of the book solely for his or her educational purposes and that he or she will not duplicate the book for use by others.

Signature: ______________________________________ Date:  _______________
 Coordinator of Services for Students with Disabilities/ADA Compliance Official