ALTERNATE MEDIA REQUEST FORM

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ALTERNATE MEDIA REQUEST FORM

Bertolini Hall| 707-527-4890 drdaltmedia@santarosa.edu

Important: When you sign & submit this form you are certifying that you have purchased/rented your textbooks (or will) in order to receive Alternate Media. (It is ok to order your Alt Media before you purchase/rent so we can get it started asap.)

Name*

First Name

Last Name

Student ID Number*

Phone*

Email*

Term*

Date

AFFIDAVIT OF OWNERSHIP

Proof of Purchase requirement for Instructional Materials received

Please check the box to acknowledge ownership*

I acknowledge that I have acquired and/or will acquire and accept full ownership of the instructional material(s) required for this Alternate Media Request.

Signature*

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Use your mouse or finger to draw your signature above

LAWFUL USE OF ELECTRONIC-TEXT FILES The disk or file containing the electronic version of the printed instructional material (identified in this Request Form) will be copy-protected or the college will take other reasonable precautions to ensure that the student does not copy or distribute the electronic version of the instructional materials in violation of the Copyright Act of 1976, as amended (17 U. S. C. Sec. 101, et seq.).