IMANI INTERPRETERS REGISTRATION FORM
Name: ________________________________________________________________________________________ First Middle Last
Address: _______________________________________________________________
City: _____________________________ State:_________ Zip: ____________
Telephone No: (home) ____________________________ (work) ___________________________
Email: ________________________________________________
What is your second language? _______________________________
Country of Origin: _____________________________________________
Level of Education: _____________________________
Where did you learn your second language? ________________________________________________
What training are you interested in attending? _____________________________
Will you be paying the $100.00 for the assessment? NO.
If not please include name and address of where to bill for the assessment.
Contact names: Pamela Jones
Name of business: Mary Washington Hospital
Address: 1000 Sam Perry Blvd
City/State/Zip code: Fredericksburg, VA 22401
Phone number: 540.741..2655
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Please attach a one page paper indicating why you want to take this training why you feel you are a good candidate and what you expect from this training.
In what settings have you previously interpreted: ________________________
Court __________ Clinic ________________ Law Enforcement ____________ Hospital __________
Social Services: ________________ other (please explain) _________________________________________________________________________________________
_________________________________________________________________________________________
___________________________________________________________________________________
Is there an organization that will be paying for your interpreter training? _____X_____yes __________no
If Yes, please fill out the following lines:
Sponsoring Organization: MWH – IMANI
Contact Name of Sponsoring Organization: PAMELA JONES
Job Title: CULTURAL SERVICES COORDINATOR
Address of the organization: 1000 SAM PERRY BLVD
City: FREDERICKSBURG State: VA Zip: 22401
Phone: 540.741.2655
Fax to Rosemary Rodriguez 804 597.2313 or email [email protected]
_________________________________________________________________________________________________________________________
Employment Eligibility Verification – Form I9
Department of Homeland Security
U.S. Citizenship and Immigration Services