Deaf Interpreter Services Inc.

Please Provide The Following Information :

Today's Date
- mm / dd / yy

Date of Appointment
- mm / dd / yy

Time of Appointment

Deaf Client's Name
First Last

Type of Appointment / Meeting

Location / Address of Appointment

City, State
Zip

Estimated Duration of Appointment

Contact Information Name & Phone :

Name	First Last
Title
Organization
Work Phone	Area Code Number
Fax	Area Code Number
Email

Name & Phone of Person Making Request :

Name	First Last
Work Phone	Area Code Number

Please Select Method of Payment :

Bill Me Information:

Company Name

ATTN TO

Address

City, State

Zip Code

Purchase Order #

Credit Card Billing Information :

Billing
Visa MasterCard American Express

Card Holder Name
First Last Initial

Card Number

Statement Address

Expiration Date
- mm / dd / yy

** 3% handling fee will be applied **

Additional Information / Comments :

*Requests received with less than 24 hour notice will be billed at Time-and-a-half*
*Less than 24 hour cancellation will be billed in its entirety*
(*Legal assignments require 48 hour notice for scheduling * cancellations*)
*Client �NO-Shows� will be billed for in its entirety*
*24 hr. cancellation notice is required per day for assignments lasting more than one day*
(i.e. a two day event requires 48 hr notice, a three day event requires 72 hr notice)