Alternate Format Course Materials (AFCM) Request Form

NOTE: In order to best track accommodations request, we ask that all AFCM request forms are submitted electronically to the email listed below.

Date: / Phone number:
Student’s Name: / Banner ID
And email:

In order for your books to be processed you MUST provide proof of purchase for all required textbooks when sending request. Please attach this to an email to .

Course Name / Course Department,Number and Section / Course Instructor / Only REQUIRED books:
Book Title, Author, Edition, ISBN, Year,Publisher

In submitting this request for Alternate Format Course Materials, I agree and verify that:

I am enrolled for the semester and the particular courses indicated above.

I am registered with and approved for this accommodation by Disability Services at SLU.

When collecting AFCM, some publishers require that the DS office share my name with the publisher. This information is provided solely for the purpose of the publisher having assurance of legitimate student participation in said course. DS will only share my name with the publisher if it is a requirement necessary to receive AFCM from the publisher.

I will verify purchase of the above mentioned materials prior to receipt of the AFCM.

I will not copy, reproduce, share, nor allow anyone else to copy, reproduce, or share the alternate format course materials pursuant to the requirements of the copyright revision act of 1976 as amended (17 U.S.C. §101 et seq.)

I will return the borrowed AFCM and applicable equipment to Disability Service at the end of the course. Failure to do so may impact my ability to use AFCM in the future and may also result in a hold being placed on my Banner account.

I understand that any violation of this agreement may be considered a violation of the university’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 proceedings and payment of fines or other moneys to the copyright holder. Furthermore, if I violate this agreement, the publisher may not be required to provide electronic formats of any other instructional materials to the university for me to use.

Sign:Date:

(when emailing form, please enter your full name and initials as signature).

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