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.

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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