Digital Textbook Request Form

Your E-mail Address *

Comments

Textbook Information

Textbook Author's Last Name *

Preferred File Format for digital textbook being requested (optional)

HTML

Web Page

DAISY 2005

Talking Book

RTF WITH

Textfile with Images

RTF WITHOUT

Text File Without Images

WORD WITH

Word File with Images

WORD WITHOUT

Word Files without Images

EPUB

For use with e-readers (e.g. iPad)

Textbook Title *

Textbook Author's First Name *

Textbook ISBN

Contact Information

School Name and Mailing Address *

Provide name and mailing address of school where student is enrolled

Digital Rights Manager Full Name *

Digital Rights Manager's E-Mail Address

Verification of Student Eligibility

I am requesting this digital textbook for a student whose qualifying disability is *

I have the complete NIMAS Eligibility Form on file, and it has been signed by the following "Competent Authority" for this disability type: *

A copy of the print version of the digital textbook requested has been purchased and is available for student use: (optional)

Yes

Don't Know/Not Sure

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