Interpreter Request Form

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

Have you read our Interpreting Services Contract?
Yes    No:  Read and Sign Now

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