| Name |
|
| Organization
(if applicable) |
|
| Street
Address |
|
| City |
|
| State |
|
|
| Zip |
|
| Phone/TTY |
|
| Fax |
|
| Email |
|
| Type
of Assignment |
|
|
| Description
of Assignment |
|
| Date
of Assignment |
|
| Starting
Time |
|
| Ending
Time |
|
| Purchase
Order Number/or Today’s Date |
|
| Location
of Assignment (address, directions, parking instructions, closest Metro stop) |
|
| Event
Facilitator or Presenter |
|
| Name(s)
of Deaf Customer(s) |
|
| Language
Preference |
|
|
|
| Preferred
Interpreter (if applicable) |
|
| Primary
On-site Contact |
|
| Cell
Phone/Pager |
|
| Back-up
Contact (manager, receptionist, event planner,
building security guard) |
|
| Back-up
Phone/Pager |
|
| Additional
Comments |
|
|
|
