DSC Interpreter Request Form

1) Deaf consumer name(s)*:

2) Please enter your contact information:

Name:*
Organization:
Street Address:*
Address (cont.):
City:*
State:*
Zip Code:*
Phone:*
FAX:*
Email:*
Alternate Contact Person:
Alternate Phone Number:

3) Billing information:

Same as contact information above

Name:
Street Address:
Address (cont.):
City:
State:
Zip Code:
Phone:

PO # or Client # (if applicable):

4) Assignment Date & Time:

Start date*:

MM/DD/YY

End date*:

MM/DD/YY

Start time*:

HH:MM AM/PM

End time*:

HH:MM AM/PM

Day of the week*:

Monday Tuesday Wednesday Thursday Friday
Saturday Sunday

multiple days:

5) Assignment Location:

Same as contact information above

Organization:
Street Address:
Address (cont.):
City:
State:
Zip Code:
Phone:
Specific location:

Other Details:

6) Assignment Details:

class

meeting

job interview

medical appointment

mental health appointment

legal appointment or court

wedding

funeral

other (give details in comments section below)

7) Expected attire for this event:

formal

business casual

casual

8) Comments and questions:

By submitting this request, you agree to the terms and procedures below:
A fax or email will be sent to your office to confirm your request and give you an approximate cost of the assignment. In the event that Deaf Service Center of Southwest Florida, Inc. is unable to provide an interpreter, your office will be notified as soon as possible, no later than 24 hours (1 business day) before the scheduled assignment. If your organization needs to cancel this request, Deaf Service Center of Southwest Florida, Inc. must be notified as soon as possible, no later than 24 hours (1 business day) prior to assignment. If cancellation notification is not made, the Deaf Service Center of Southwest Florida, Inc. will bill for the total amount of your request.

For EMERGENCY MATTERS, please call (239) 461-0334 ext. 7 to be transferred to the on-call interpreter.