Interpreter Request Form Please complete and fax to 248 3327334email to deafcandeafcanorgSn M T W TH F S DATEStart Time ampm End TimeampmWhen your request is filled a confirm ID: 895864
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1 DEAF COMMUNITY ADVOCACY NETWORK Interp
DEAF COMMUNITY ADVOCACY NETWORK Interpreter Request Form. Please complete and fax to: (248) 3327334email to deafcan@deafcan.orgSn M T W TH F S DATE:____________________Start Time:________ am/pm End Time:________am/pmWhen your request is filled, a confirmation will be faxed to you. If you do not receive a confirmation, please call DEAF C.A.N.! Name:________________________________________________Title:______________________Unit #___________________Company:____________________________________________Phone:_______________________________________________Fax:__________________________________________________ Client Information: (please provide detailed information) Deaf Person’s Name:__________________________________Type of Assignment:__________________________________Case /P.O.#:_____________ Location of Services: (Please provide detailed information) Name:___________________________ ON SITE CONTACT’SNAME/PHONE NUMBER:_______________________________Address:________________________________________________________________________Directions:__________________________ __________________________________________ Billing Information: Na浥:彟_彟_彟_彟_彟_彟_彟_彟_彟_彟彟_彟_彟_彟_彟_彟彟_彟_彟_彟_彟_彟彟_彟_彟_彟Addre獳:彟_彟_彟彟彟_彟_彟_彟_彟_彟彟_彟_彟_彟_彟_彟彟_彟_彟_彟_彟_彟彟_彟_彟_彟Cit示彟彟_彟_彟_彟_彟_彟_彟_彟_彟_彟彟_State:_彟_彟_彟彟_Zip:彟_彟_彟彟彟_彟_彟_彟Attention:_彟_彟_彟彟_彟_彟_彟_彟_彟彟_彟_彟_彟_彟_彟_P.O.:_彟_彟_彟_彟彟_彟_彟___ Cancellation Canceled by:____________________________________________ Date/Time Date & Time Interpreting Service s are Needed : Interpreter Assigned: FOR OFFICE USE ONLY Interpreter Copied:_______________ Book Entry:____________________ Signature:_ ____________________________________________________ ~ Please Print Name and Sign ~ Interpreting Rates Effective: January 2019 Regular Rate (first two hours) 7:00 am5:00 pm $96.00Each additional hour $48.00 After Hours/Weekend/Holiday Rate (first two hours) 5:00 pm High Risk Rate (first two hours) Psychiatric Evaluations, Attorneys, Hospital Emergency Rooms, Jails, etc.High Risk $110.00Each Additional Hour $ 55.00 Court Rate (first two hours) Court Rate $136.00Each Additional Hour $ 68.00 Emergency Pager Rate (248) 5231998 Each Additional Hour $ 70.00 An invoice will be sent for these services in approximately two weeks. Credit cards are accepted for payment of this invoice. To pay the invoice after receipt, please call DEAF C.A.N.! Deaf Community Advocacy Network 2111 Orchard Lake Road #101Sylvan Lake, MI 48320 (248) 332 - 3331