Federal Quota Ordering Form

Use this form to order Braille, large print, and other format materials from the American Printing House for the Blind (APH). Select the material you need from one or more of the APH's educational or independent living product catalogs available at www.aph.org. When completing the form, be sure to include the catalog number, the number of items you'd like, and an accurate description for each item requested.

Item Information

Product name:

Catalog number:

APH catalog numbers are usually in the form X-XXXXX-XX or X-XXXXX-XXX

(Other product name):

Quantity:

Student first name:

Student last name:

Date of Federal Quota signed parent permission on file:

Add another item

Product name:

Catalog number:

APH catalog numbers are usually in the form X-XXXXX-XX or X-XXXXX-XXX

(Other product name):

Quantity:

Student first name:

Student last name:

Date of Federal Quota signed parent permission on file:

Product name:

Catalog number:

APH catalog numbers are usually in the form X-XXXXX-XX or X-XXXXX-XXX

(Other product name):

Quantity:

Student first name:

Student last name:

Date of Federal Quota signed parent permission on file:

Product name:

Catalog number:

APH catalog numbers are usually in the form X-XXXXX-XX or X-XXXXX-XXX

(Other product name):

Quantity:

Student first name:

Student last name:

Date of Federal Quota signed parent permission on file:

Product name:

Catalog number:

APH catalog numbers are usually in the form X-XXXXX-XX or X-XXXXX-XXX

(Other product name):

Quantity:

Student first name:

Student last name:

Date of Federal Quota signed parent permission on file:

Product name:

Catalog number:

APH catalog numbers are usually in the form X-XXXXX-XX or X-XXXXX-XXX

(Other product name):

Quantity:

Student first name:

Student last name:

Date of Federal Quota signed parent permission on file:

Product name:

Catalog number:

APH catalog numbers are usually in the form X-XXXXX-XX or X-XXXXX-XXX

(Other product name):

Quantity:

Student first name:

Student last name:

Product name:

Catalog number:

APH catalog numbers are usually in the form X-XXXXX-XX or X-XXXXX-XXX

(Other product name):

Quantity:

Student first name:

Student last name:

Date of Federal Quota signed parent permission on file:

Product name:

Catalog number:

APH catalog numbers are usually in the form X-XXXXX-XX or X-XXXXX-XXX

(Other product name):

Quantity:

Student first name:

Student last name:

Date of Federal Quota signed parent permission on file:

Product name:

Catalog number:

APH catalog numbers are usually in the form X-XXXXX-XX or X-XXXXX-XXX

(Other product name):

Quantity:

Student first name:

Student last name:

Date of Federal Quota signed parent permission on file:

Requestor Information

First Name:

Last Name:

Requestor Email:

U.S. phone number:

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The requestor agrees to the following terms:

Requester confirms that they have formal documentation as a record that the student meets the definition of blindness or functions at the definition of blindness as defined by APH and will maintain this record in the event of an audit.
The materials requested will be used for the student(s) on request form.
EOT reserves the right to request the return of materials when a FQ student is no longer using them.
To the best of the requestor’s ability, product packaging will be kept for the return shipment.
The Pennsylvania EOT is responsible for approving or declining FQ lending library requests.

Requestor initials:

Ship to Information

First Name:

Last Name:

All APH orders must be sent to a school, agency, or organization unless prior permission is granted.

School/Organization/Agency name:

Address 1:

Address 2:

City:

State:

U.S. ZIP code:

Email:

U.S. phone number:

( ) -