Electronic Text Request Form

* Required Field

Book Information

Author Last Name*

Author First Name*

Book Title*

Edition*

ISBN*

Copyright Year*

Publisher*

Requestor Information

Semester*
Spring Summer A Summer B Fall Winter

Year*

Student's Last Name*

Student's First Name*

Student ID Number (Student A#, not SSN)

Student Birth Date*

Student PCC Email*

Student's Primary Disability*

Course CRN*

Course*

Campus*
Community Desert Vista Downtown East Northwest West

Instructor*

Alt Format Information

Preferred format*
Plain Text PDF MS Word RFB&D (Include RFB&D # in comments) Other (Specify in comments)

Alternate format
Plain Text PDF MS Word RFB&D (Include RFB&D # in comments) Other (Specify in comments)

Assistive Technology on Campus*

Assistive Technology at Home*

Student Requests AT Training
Yes  No

Specialist Information

Disability Specialist's Last Name*

Disability Specialist's First Name*

Specialist's Phone Extension*

Specialist's Mail Code

Please include specific information about how the student prefers to use the material. For example:

• student uses JAWS and prefers MS Word format
• student uses MAGic and prefers color PDF files with Adobe tags
• student uses RFB&D but can use text files with Natural Reader or WYNN if not available etc.

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