To help us expedite your request for an interpreter, please fill out the following form as completely as possible. One of our DIS service representatives will be in touch with you shortly regarding your request. We normally respond within 30 minutes of receiving your request.

When submitting a request in the evening or on the weekend, please also call the office to ensure prompt attention to your request.

Click to download printable form here.

* indicates a required field

Tell us about your appointment:
Appointment Date:* (mm/dd/yy)
 Appointment Time:*
Appointment Time Zone:*
Deaf Consumer's First Name:*
Last Name:*
Type of Appointment/Meeting:*
 Estimated Time Needed On Site:*
City:*
 State:*
Zip:*
VRI Connection Email:*

Contact Information Name & Phone:
First Name:*
Last Name:*
Title:*
 Organization:*
Work Phone*:
 Fax Number:
Email*:

Name & Phone of Person Making Request:

Same as contact information above

First Name:

Last Name:
Phone:
Email:

Payment Information:
Method of Payment:*
Company Name:*
Billing Address:
City, State:
Zip:
Purchase Order #:
Accounting Contact Name:*
 Accounting Contact Phone:*
Accounting Email: (if you want invoice emailed)

Credit Card Billing Information:

Please provide the following information if you wish to pay via credit card.
Card Type:
Name As It Appears On The Card:
 Card Number:
Billing Address:
City, State:
 Zip:
Expiration Date: (mm/yy)

Additional Information / Comments:
  • Last minute cancellations and client “No-Show” will be billed at the 30 minute minimum or the actual time requested, whichever is greater.
  • Requests received with less than 48 hour notice will be billed at Time-and-a-half
  • Less than 48 hour cancellation will be billed in its entirety
  • Legal assignments require 48 hour notice for scheduling &/or cancellations
  • Client “No-Show” 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)