Disability Request Form

Disability Request Form

Please provide all of the following information to ensure a timely response.

Heinemann Publication Information

Please ensure the title is actually published by Heinemann before submitting.

Number of Heinemann Titles to Request:*

Please note if you are requesting more than three titles you will need to submit this form again.

Requested Title:*

Request Author(s):*

Request Copyright Year:*

Request ISBN:*

Second Requested Title:*

Second Request Author(s):*

Second Request Copyright Year:*

Second Request ISBN:*

Third Requested Title:*

Third Request Author(s):*

Third Request Copyright Year:*

Third Request ISBN:*

Requesting School's Information

College/University/School Name:*

Address Line 1:*

Address Line 2 (optional):

City:*

State:*

Zip:*

Check if address is within the United States:

Non-U.S. Country:*

Course/Class:*

Semester:*

Software Used to Read File, if available:

The request is for:*

Teacher

Student

Accessibility Coordinator's Contact Information

Coordinator First Name*

Coordinator Last Name*

Coordinator Title*

Coordinator Email*

Coordinator Phone*

Phone

Terms of Use Agreement

Heinemann requires you to sign a Terms of Use Agreement before being provided the requested file. Would you prefer to print, sign, scan and return the agreement via email or have us send you a file for e-signature via DocuSign?*

Print/sign/scan/return via email

E-signature via DocuSign

Send me a copy of my responses

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