Interpreter Request Form

Thank you for providing effective communication as required by the Americans With Disabilities Act Title III

Assignment Information

Deaf Individual's Name
Assignment Location
Assignment Address
Suite/Room #/Floor
Building Name (if applicable)
On Site Contact Person  
Special Instructions for locating or accessing building
Assignment Date
(If multiple day request, type "Multiple)
Start Time
End Time
Has the Deaf Individual requested specific interpreters? Yes   No
If so, please list names
Has your business or organization worked with Deaf individuals before? Yes   No 
Assignment Description
Are there support materials available?
(i.e. agenda, PowerPoint, syllabus, etc)
yes   no
If so, please send them at your earliest convenience to
Other requirements No Cell phone permitted
ID Required
Specific Clothing Required
Specific Footwear Required
Other (please describe)

Parking Availability
Specific Parking Directions?
Whom may we thank? How did you hear about us?  


Billing Information

Business/Organization Name
Billing Contact
Billing Address
If invoice can be submitted via email, please provide email address.
Do you have any other questions for LIM?

Submit Form