Appendix B    Publisher Request/Student Agreement Form
Publishing Company

Part A¹  Publishing Company Electronic Text Request Certification

In order to process your request to assist a student with disabilities, please complete this form, including the required signatures, and return it to: (name, address, phone, fax)

Technology Currently Used by Student (optional):

Certification of Coordinator of Services for Students with Disabilities or ADA Compliance Official

• I certify that the institution has purchased the printed instructional material for use by the student named above or that the student has purchased the printed instructional material.
   
• I certify that the requesting student has a disability that prevents him/her from using standard instructional materials. Proof of student disability will be kept on file at the college.
   
• I certify that the instructional material requested is for use by the student in connection with a course in which the student is registered or enrolled at the university, college or campus listed above.
   
• I certify that the student with a disability has signed the Student Agreement on the Use of Recorded, Electronic or Other Alternatively Formatted Course Materials and the signed Agreement will be kept on file at the college.

¹Part A should be returned to the publishing company at the address provided above.

Part B Agreement by Student

Agreement on the Use of Recorded, Electronic or Other
 Alternatively Formatted Course Materials

• I agree that I am enrolled for the semester and the particular course(s) for which I am requesting alternatively formatted instructional materials.
   
• I have provided the designated college official with appropriate documentation of the disability that prevents me from using standard instructional material.  I understand that this documentation will be kept on file at the college.
   
• I understand that I must purchase instructional materials at the same cost as other students.
   
• I agree that I will not copy or reproduce alternatively formatted instructional materials nor allow anyone else to do so pursuant to the requirements of the copyright revision act of 1976 as amended (17 U.S.C. §101 et seq.).
   
• I will not share alternatively formatted materials with any other party.
   
• I understand that any violation of this agreement may be considered a violation of the college’s Student Code of Conduct and may result in penalties including suspension and expulsion.  Violations may also constitute a violation of federal and/or state laws and may result in civil or criminal prosecution, payment of fines or other moneys to the copyright holder, and/or incarceration.

I have read and understand the policies and procedures outlined above and agree to comply with them.

Part A should be returned to the publishing company at the address provided above.
Parts A and B should be retained in the institution’s files.
 

OQA Home l Memo l Memo and Forms in: Word l PDF