Student Name: 


Address:
Street   City   
State  Zip  Telephone 

Original Request   Add-On Request

Please select those services which you are requesting for the 2006-2007 academic year.  If you have questions or need further information, please call the department Resource Center at 287-5089 (V/TDD). 

* You must have an RFB number to receive recorded textbook services.  Please write the number in the space indicated above.

I am requesting the services indicated above because of a physical, mental or learning disability as identified in the Vocational Rehabilitation Act of 1973.  Eligibility for these services has been explained to me and I have received information on the procedures for accessing the approved services.

Please type your name here as your signature