Interpreter Request Form

Print Form
Submit by Email
PO Box 4427 | Salinas, CA 93912 | www.interpretnmf.com
Interpreter Request Form
Please fill out the request form as completely as possible. This request is NOT a confirmation of an interpreter. We will
contact you as soon as your request has been received. If you would like to inquire about your status, please email us at
[email protected] or call us at 1-855-662-5300. Thank you and we look forward to doing business with you.
*Required Fields
CLIENT INFORMATION
*Company Name:___________________________________________*Department:______________________________________________
*Doctor/Client Name (whose appointment will be interpreted):___________________________________________________________________
*On-Site Contact Person:____________________________________*Email Address:____________________________________________
*Phone Number (including cellphone for last minute needs):_____________________________________________________________________
APPOINTMENT DATE & LOCATION
*Date(s): _____________________ to ______________________
*Time(s): _____________________ to ______________________
(NOTE: There is a 1-hour minimum appointment)
*Service Site Name:______________________________________
*Service Site Address:____________________________________
_______________________________________________________
*Specific Location Instructions: (Which building, office number, etc.
“Meet at table in conference room. Park in any uncovered parking stall.”)
TYPE OF APPOINTMENT
*Type of Appointment:
Medical
Legal
Other_____________________
Appointment/Meeting Details: (Be as descriptive as possible about
the nature of the appointment, so that we can provide the best possible
interpreter(s) for the job.)
_______________________________________________________
_______________________________________________________
_______________________________________________________
LANGUAGE DETAILS
_______________________________________________________
*Language:_____________________________________________
_______________________________________________________
(If you cannot distinguish which Indigenous Language you need, please
call us at 1-855-662-5300 and we can help)
_______________________________________________________
*Special Instructions or Needs:____________________________
*If a Phone Meeting: Call-in Number:________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
ADDITIONAL INFORMATION
*Any additional information about this appointment that would be helpful for us to know when choosing among our Interpreters?
(i.e. sensitive women’s appointment, so prefer a woman)
_________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
BILLING INFORMATION
CONTACT PERSON (to confirm appointment details)
*Email Invoice to:___________________________________
*Name:____________________________________________
*Mail invoice to: (Agency Name):________________________
*Phone Number:____________________________________
*Address:__________________________________________
*Email:____________________________________________
*City, State, Zip:____________________________________
Have we interpreted for you previously?
How did you hear about us? __________________________________________________________________________
Yes ✔ No
Rev 11/13