Student Information
Be sure to provide your contact information in case we need to contact you.
Date Request:
*
Semester/Year
Student Name:
*
Student ID:
E-mail address:
*
Telephone:
I have been approved by DSS Advisor to receive alternate media services:
*
Yes
No
I am registered in the classes for which I am requesting alternate media:
*
Yes
No
I have (or will be able to provide) proof-of-purchase for the textbooks I am about to request in alternate media:
*
Yes
No
I have searched for accessible digital versions (ePub and ebook) of my books on Vitalsource, the SSU Bookstore, or other ebook provider (make certain ebooks have a "Read Aloud" option).
Yes
No
My text-to-speech/screen reader/screen magnifier is/are:
Read&Write
ZoomText
JAWS/VoiceOver/NVDA
Other
My alternate media preference is/are:
Braille
Microsoft Word
PDF
Enlarged Prints
ePUB (digital books)
Other
Back
Next
Save
Textbook Information
To expedite your request, please provide as much information as possible. The best way for us to locate your book is by its exact title, edition and ISBN number. You may enter information for up to 10 titles.
Textbook #1:
Course:
*
Professor:
Book Title:
*
ISBN:
Author(s):
*
Publisher:
Edition:
*
Do you have more textbook to request?
*
Yes
No
Back
Next
Save
Textbook #2:
Course:
*
Professor:
Book Title:
*
ISBN:
Author(s):
*
Publisher:
Edition:
*
Do you have more textbook to request?
*
Yes
No
Back
Next
Save
Textbook #3:
Course:
*
Professor:
Book Title:
*
ISBN:
Author(s):
*
Publisher:
Edition:
*
Do you have more textbook to request?
*
Yes
No
Back
Next
Save
Textbook #4:
Course:
*
Professor:
Book Title:
*
ISBN:
Author(s):
*
Publisher:
Edition:
*
Do you have more textbook to request?
*
Yes
No
Back
Next
Save
Textbook #5:
Course:
*
Professor:
Book Title:
*
ISBN:
Author(s):
*
Publisher:
Edition:
*
Do you have more textbook to request?
*
Yes
No
Back
Next
Save
Textbook #6:
Course:
*
Professor:
Book Title:
*
ISBN:
Author(s):
*
Publisher:
Edition:
*
Do you have more textbook to request?
*
Yes
No
Back
Next
Save
Textbook #7:
Course:
*
Professor:
Book Title:
*
ISBN:
Author(s):
*
Publisher:
Edition:
*
Do you have more textbook to request?
*
Yes
No
Back
Next
Save
Textbook #8:
Course:
*
Professor:
Book Title:
*
ISBN:
Author(s):
*
Publisher:
Edition:
*
Do you have more textbook to request?
*
Yes
No
Back
Next
Save
Textbook #9:
Course:
*
Professor:
Book Title:
*
ISBN:
Author(s):
*
Publisher:
Edition:
*
Do you have more textbook to request?
*
Yes
No
Back
Next
Save
Textbook #10:
Course:
*
Professor:
Book Title:
*
ISBN:
Author:
*
Publisher:
Edition:
*
Back
Next
Save
Proof-of-purchase:
In order to process your request, the Alternate Media Center needs to have proof-of-purchase for each of the books you about to request. You may attach copies of your receipts, e-mail confirmations, etc. in PDF or image files such as JPEG , PNG, TIF, GIF. High resolution images taken with a smartphone are acceptable.
Upload Attachment
Select file(s)
Drag and drop files here
Choose a file
Hold down the Ctrl (Windows) or Cmd (Mac) key to select more than one attachment
Cancel
of
If you are NOT able to provide proof-of-purchase at this point, please tell us briefly how and when will you be able to do so? (Notice: This will delay our process to obtain E-text/alternate format of the textbooks for you):
Back
Next
Save
Please read and agree with the following terms before you submit:
I understand that to receive the alternate format of these textbooks, I must first buy a print copy of the same textbooks as stated in California state law Assembly Bill 422. I understand that I may in no way duplicate or distribute any disk or file containing the electronic version of these textbooks. I understand that doing so is a violation of the Copyright Act of 1976 as amended (17 U.S.C. Sec 101, et seq.).
*
I Agree
I Don't Agree
Save
Submit Request
Should be Empty: