State Services for the Blind

Requestor’s Order For Transcribed Materials

Instructions : Please fill out the following form in your web browser, print it out (the "Print Form" button is at the bottom of the form), and mail it along with a copy of the book to:

Communication Center
State Services for the Blind
2200 University Avenue West #240
St. Paul MN 55114-1840
Toll Free: 1-800-652-9000
Phone: 651-642-0500
TDD: 651-642-0506
FAX: 651-649-5927

(Orders not filled in completely will be returned)

Upon receipt of this order, the Communication Center will return a copy as acknowledgement of receipt.

Date Received (for office use only): ______________

Material Information Provide the following material in: BRAILLE CASSETTE
Number of Copies:
(Note: If you need a book in braille and on tape,
2 Requestor's forms and 2 copies of the book are required)

Purchase Order Number:
Accession Number:	(Confirmed by CC Librarian)

Title:
Edition:
Authors:
Publisher:
Copyright Date:
ISBN #:
Subject:
Class Level:

Please Note: It is essential that you include an assignment schedule with this form along with specific due dates for installments. This will assist us in providing installments on time and allow us to serve you better.

Course Information

Course Title & Number:

I will be using this book during the entire school year of OR

Summer - From:		To:
Fall - From:		To:
Winter - From:		To:
Spring - From:		To:

Student Information

Student Name:
Specific Disability:
Current Mailing Address:

Permanent Address:

Phone Number:
Alternate Phone Number:
Email:

School Information

School Name:
Contact Name:
Mailing Address:

Billing Address if different:

Phone Number:
Summer Phone Number:
Email:

Other

Mail transcriptions to address for:	Student School Other (List Here):
Return original print copy to address for:	Student School Other (List Here):
Label Cassettes with Braille?	Yes No

Special Instructions (Information on how you want graphs, tables, etc. handled; whether you want preface, introduction, contents, glossary, appendices, etc. transcribed):

Authorized Signature : _______________________________

Date :