Date:

Trustee/Purchaser Name:
Address:
City:
State:    Zip:
Phone:
Email:

Teacher's Email Address:

Title of Book:
Publisher:
ISBN #:
Grade Level
Copyright Date
Edition:  National   State

Braille Pages:  1-Sided    2-Sided    Double Spaced

Binding Style: ATIC hard cover/spiral bound

Consumable?:  Yes    No

Include all Tables and Charts?:  Yes    No

Standard Codes Used:  Nemeth    Computer    Literary   Text Book Format   Music

Type of Braille Used:  Contracted   Uncontracted

Braille Format:
40 Characters/20 lines/pg size - 11 x 8 ½
40 Characters/25 lines/pg size - 11½ x 11

State Code (if required):

# of Copies:

Requested Due Date (must include month and year):

Complete information below so we can purchase the books for you:

Book supplier/source:
Address:
City:
State:     Zip:
Phone:
Email:

Note: for books that are no longer in print or that are too difficult to secure, we will need you to send us four print copies.

Purchaser Signature:     Date:

The Trustee signature is required.

Send this completed form, Federal Quota form, and front/back cover, title page, and back of title page to:

Attn: New Custom Book Orders
American Printing House for the Blind, Inc.
1839 Frankfort Ave.
Louisville, KY 40206

Fax: 502-899-2219
E-mail: ATIC@aph.org