Student Name: Address: Street City State Zip Telephone
Original Request Add-On Request
Please select those services which you are requesting for the 2007-2008 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