If you need Video Remote Interpreting services please make sure you choose that option at the very end of this form!Requester's Name *Requester's Email Address *Requester's Phone Number *Billing InformationCompany/Organization Name *Name Of Company or Organization Paying For Services0 / 180My Organization Already Has An Account With AZFLISYes, we have had services provided by AZFLIS previously.No, we need to get an account setup.New Customer Account Setup InfoWe look forward to providing a remarkable interpreting experience for your organization. We do need to get a rate sheet on file to get your account setup in our scheduling software first. Please download the AZFLIS Rate & Policy Sheet and email the completed form to firstname.lastname@example.org Feel free to contact our office for more information at 480-595-9515Appointment Scheduling InformationPlease Provide As Much Information As You CanDate Of Service *Start TimeHours-120102030405060708091011Minutes-000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859AMPMEnd TimeHours-120102030405060708091011Minutes-000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859AMPMStreet Address *Apartment, suite, etcCity *State/Province *ZIP / Postal CodeSelect Location Building Type *Please select an optionMedical complexStandalone office buildingStrip mall or other business complex.Residential - HomeResidential - AppartmentIs Your Company/Business Name On The Building At The Address Listed Above? *NoYesName on building or other identifiable information. *Appointment DetailsDeaf Consumers Name *Interpreting Service Needed *Please select an optionAmerican Sign LanguageTeam (2 interpreters) American Sign LanguageAmerican Sign Language - Legal CertifiedCART ServicesCDI - Certified Deaf Interpreter & American Sign Language TeamTactile InterpretingVRI - Video Remote InterpretingAppointment Type *Please Choose Appropriate Appointment Type HereCase ReviewConference/WorkshopCommencement CeremonyEducational ClassEducational MeetingFuneralHospital EmergencyHospital InpatientJob InterviewLegal MatterLive Performance/ConcertMedical AppointmentMeetingOutdoor ActivityReligiousSportsTrainingLegal Assignment Type *Please select an optionArraignmentClient/Attorney MeetingClassificationCourtroom HearingCourtroom TrialCrime SceneDepositionInterviewMediationOrder Of ProtectionTo Assure Interpreters Are On Site, On Time.Please be aware, the interpreter will be scheduled 15 minutes prior to the scheduled start time to assure that they have time to park, gain entrance and find their designated area to perform on time.Travel Time NotificationPlease be aware, portal to portal travel time will be billed for any medical emergency including hospital emergency room visits.Where does the interpreter need to check in? *Will the interpreter be recorded? *Please select an optionYesNoWill the interpreter be on stage? *Please select an optionYesNoWhere does the interpreter park, is it free, can it be validated? *Special instructions to gain entrance if there is a gated entrance or entry fee? *Is this for a specific deaf individual or just in case deaf attend? *Please select an optionServices are for the deaf individual I listed above.Services are setup just in case any deaf individuals attend.Can we get copies of sermon or any other speaking points, songs, etc. *Please select an optionYesNo, I do not have access to this information.What religion will be observed by the attending? *This helps us assure we find an interpreter that is a good fit for the event.What is the name of the conference and what is the nature of the content being presented? *Is there a script or other materials available before hand? *Please select an optionYes, I will send this to the agency or upload them later.NoWhat type of setting; funeral, church services, religious counseling...etc. *Will the interpreter need to interpret each individual name or will the names be displayed on a screen? *Will the interpreter be required to wear a cap and gown? *Please select an optionNoYes, I will follow up with the agency about sizes and where to pickup these items.Where will the interpreter be seated/positioned? *Are any deaf individuals presenting/will interpreters be voicing for anybody? *Is this for an indoor or outdoor event? *Please select an optionOutdoorIndoorCan the interpreter dress casually? *Please select an optionNo, standard interpreter attire is preferred.Yes, casual attire is fine.How many people present, deaf and hearing? *What type of review? 6 month, Annual, etc *Is this a Lecture, Presentation, Q and A session or a 1 on 1 meeting? *Class Type *Please Select Class Type HereK-12 ClassesCollege ClassesStudents Grade Level *Is there a sub folder? Where is it located? *Which building does the interpreter need to enter? *Is this a lecture style class or a lab? *What is the class/course name? *What is room number is the class? *What is the nature of the training? *Style Of Training *Please select an optionVideo Based1 on 1 job shadowingClassroom style trainingIs there as different entrance/parking after hours? *What has the patient been admitted for or complaint? *Dr. Name *What is the patient's ER bay or room number? *What type of appointment? *Is this request for a behavioral setting? *Please select an optionYesNoShould the interpreter arrive prior to appointment time for patient check in? *Is this in a medical complex? If so, where does the interpreter park and enter? *Deaf Consumer's Age *0 / 180Does the patient have a violent history? *Is the patient currently in restraints or on suicide watch/observation? *Will there be a video presentation? *Please select an optionNoYes, and there are subtitles.Yes, and there are no subtitles.Is there a speaker/presenter or is this an open format meeting? *Is deaf consumer Plaintiff, Defendant, Victim or Witness? *Please select an optionPlaintiffDefendantVictimWitnessWhat is the nature of the case? *What are the charges? *Docket, Case or Report # *Will the opposing legal counsel have their own interpreters? *Please select an optionYesNoI am not sure.How will the interpreter be utilized? *Please choose one.Proceedings InterpreterTable InterpreterWhat is the nature of the interview? *Requesting officer or detective's badge # *What type of trial is this for? *What type of hearing is this for? *Extra Information *0 / 180On Site Contact InformationPlease Make Sure We Have A Valid Contact For Our Interpreters On Site.I Am The Onsite Contact And Have Listed My Mobile Number PreviouslyThere Will Be Somebody Else On Site, Let Me Add Their Contact InfoName Of On Site Contact *Phone # Of On Site ContactPlease Provide Mobile Number If PossibleeMail Address For On Site Contact0 / 180Finalize & SubmitUpload fileChoose FileNo file chosenDelete uploaded filePlease upload any scripts, site maps or other useful documents here. Video Remote or Face To Face?Face to FaceVRI (Video Remote Interpreting)Our video remote interpreting option will help your office adhere to the social distancing requirements that the CDC has set forth.Please provide any information about the precautions being taken at the location of service for this request regarding the Covid-19 pandemic. *Submit RequestPlease do not fill in this field.