All fields required.
Your Name
Your Email
Your Phone ext.
Your Fax
Date Interpreter Is Needed (MM/DD/YY)SundayMondayTuesdayWednesdayThursdayFridaySaturday
Time Interpreter Is Needed From AMPM to AMPM
Additional Dates Needed (MM/DD/YY)
Additional Time Interpreter Is NeededFrom AMPM to AMPM From AMPM to AMPM **Note: Assignments longer than 1½ hours may require two interpreters.**
On-site address for interpreter: Company name: Address: Suite number: City: State: Zip:
On-Site Contact Name
On-Site Contact Phone ext.
Additional information/instructions for interpreter:
Name of Deaf Person(s)PatientParticipantPresenterOther
Description of AssignmentLegalMedicalMental healthSocial servicesGroup trainingOne-on-one trainingOther
Please explain: (example: follow-up doctor’s appointment, computer training, jury trial, etc.)
How did you learn about MIS?Current customerGiven name by Deaf personInternetOther
Estimate Needed
Billing Address: Company name: Department: Address: City: State: Zip: Attention To: PO number/Billing Code:
By checking this box, I understand my request will be submitted to the MIS office. When an interpreter is scheduled, I will receive a confirmation e-mail, and I will be responsible for the cost of services. I am familiar with the rates of MIS, including the policy that any request submitted with less than three business days notice will incur additional fees and any request cancelled with less than three business days notice will be invoiced in full. (For further information regarding rates and policies, please contact us.)
