Online Courseware Adoption Request Form

* = Required Fields. Your request cannot be processed if the required fields are not completed.

Sales Information

 

Requestor (Your Name):*

Requestor eMail:*

Phone Number:*

Date Requested:*

Course Start Date: *

Course End Date:*

Requested Course Title:*

Customer Information

 

Institution Name:*

Instructor Name:*

Address:*

City:*

State:*

Zip:

Instructors eMail Address:*

Instructors Contact Phone:*

Billing Information

 

Address:

City:

State:

Zip:

For Educational Institutions

 

Info below is required to process requests for Educational Institutions

Account Number:

P.O. Number:

Enter Your Sales Reps Name:

Number of Users Requiring Access:*

Does anyone other than instructor or students require reports?*
(if you answer yes, please provide details in comments section.)


Purchase Options


Will Users Purchase Access Code Packages*



Not Sure

Does Institution Need Access Code Bundled with Textbook:*



Not Sure

Additional Comments: