Document Conversion Request

This form will be considered a pre-request information message for your Learning Specialist in advance of receipt of materials.

Requests should be made at least two weeks in advance of the date when the first installment of the materials will be needed.

Each request must include the following items:

1. A completed Document Conversion Request Form;
2. A syllabus for the course in which the materials are to be used;
3. The materials (print and/or electronic copies) to be converted.

Please be sure to note when Materials will be dropped off in the Notes/Additional Information box below.

*Required Information

Your Information:
	First Name*:
	Last Name*:
	email*:
	phone*:	ext.
	Preferred method of contact*: email phone
	Learning Specialist*:	Select One Debra Bacon Jan Baptist Cindi Grew Cindy Poore-Pariseau Kathy Saltmarsh Denyse Wilhelm Unsure
	This request is being made by someone other than the person listed above (If you checked this section, please list your name and relationship to the person listed above in the comments box below)
Conversion Information :
	Conversion Type:	Please Choose Audio Tape Braille Large Print Kurzweil Electronic
	Dropoff Date:
	Comments :