Post-Secondary Alternate Format Materials Order Form

(Braille/E-text/Audio Books/Large Print)

#215 - 1181 Portage Ave.
Winnipeg, Manitoba  R3G 0T3
PH:  204-945-8157   FAX:  204-948-1321
Email   susan.doerksen@gov.mb.ca

If you need help in filling out this form, click here for Form Help.

You can also download printable versions of the Post-Secondary Order Form
PDF File ( 66 KB)
MS-Word File ( 84 KB)

 

Student Information

Student Name:	(required)
Home Address:	(required)
Postal Code:	(required)
Phone:	(required)
Email:
College or University:	(required)
Faculty:
Special Needs Coordinator:
Phone:
Fax:
Email:
Instructor:
Phone:

 

Reason for Request

Reason for request:	[ Visual Impairment] [ Physical Disability] [ Learning or Reading Disability]
Order Date:	(required)
Recording for the Blind and Dyslexic Registration Number:
Check the boxes that apply:	[ Do you need braille labels?] [ Have you ordered materials before?] [ Do you have access to a 4 track-15/16 speed cassette recorder?]
Special Instructions:

 

Item Information

Title 1: (Include alternate title):	(required)
Date Required:
Author: (Include all authors, first & last names)
Edition:
Copyright Date:
ISBN:
Publisher:
Name of Course:
Course No.:
Course Duration:
From:
To:
Is this text?	[ Required Text] [ Optional Text]
Preferred Format:	MP3 Files Audio Cassettes E-text Large print Braille E-braille (.brf)

 

Item 2 Information

Title 2: (Include alternate title):
Date Required:
Author: (Include all authors, first & last names)
Edition:
Copyright Date:
ISBN:
Publisher:
Name of Course:
Course No.:
Course Duration:
From:
To:
Is this text?	[ Required Text] [ Optional Text]
Preferred Format:	MP3 Files Audio Cassettes E-text Large print Braille E-Braille (.brf)

 

Submit, Clear, Cancel

If there are additional titles you wish to borrow, please make a copy for your file, submit this form, clear it from your screen, fill it out again and submit the next order.
Submit, clear, or cancel:

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