OFFICE OF PROFESSIONAL REGULATION APPLICATION TO BE AN SIGN LANGUAGE INTERPRETER The fee for this application is $25. 1. FULL NAME: _______________________ _____________________ _________________ Last First Middle 2. MAILING ADDRESS: ____________________________________________________________ Street Address or P.O. Box Number _______________________ _________ City State 3. TELEPHONE NUMBER: __________________ Residence _____________ Zip Code ________________ County _________________ Cell _________________ Work 4. EMAIL ADDRESS: ________________________________ 5. BIRTH DATE: ___________________ (MM/DD/YYYY) 6. EDUCATION A. How many years of formal education have you completed: __________ (Include all levels of education, not just college) B. List all colleges and universities you have ever attended regardless of whether you received any credit. COLLEGE OR UNIVERSITY MAILING ADDRESS DATES ATTENDED CREDIT/DEGREE AND AREA OF STUDY AGE: __________ C. List all high schools you have ever attended regardless of whether you received a diploma. HIGH SCHOOL MAILING ADDRESS DATES ATTENDED DIPLOMA RECEIVED 1 American LegalNet, Inc. www.FormsWorkFlow.com 7. LANGUAGES LIST THE TYPE OF SIGN LANGUAGES IN WHICH YOU HAVE SUFFICIENT EXPERTISE TO BE A COURT INTERPRETER HOW MANY YEARS HAVE YOU USED THIS SIGN LANGUAGE? 8. CERTIFICATES Check the sign language certificates you have obtained. (You must have at least ONE of these): Certificate of Trasliteration (CT) ­ AND ­ Certificate of Interpretation (CI) Comprehensive Skills Certificate Certificate of Deaf Interpreter (CDI) or CDI-P (provisional) certificate Interpreters for the Deaf from the Registry of _______ A. I have obtained a specialist certificate: legal (SC:L) Yes/No NOTE: If yes, you are considered a "certified sign language court interpreter," and you do not have to attend a Court Interpreter Orientation Seminar. How did you learn sign language? 9. COURT INTERPRETING EXPERIENCE _______ A. How many times have you interpreted in court? If you have interpreted in court please list the types of cases _______ B. How many times have you interpreted in places other than court? Please describe these experiences. 2 American LegalNet, Inc. www.FormsWorkFlow.com _______ C. How many times have you performed simultaneous (you interpret continuously while someone speaks) interpretation in court? _______ D. How many times have you performed consecutive (a person speaks, then stops while you interpret, then speaks again, etc.) interpretation in court? _______ E. How many times have you performed sight interpretation of documents (you read a document and verbally interpret what it says) in court? 10. EMPLOYMENT Current Occupation Current Employer Employer Address Employer Phone and Email 11. CIVIL OR CRIMINAL PROCEEDING BACKGROUND _______ A. Have you ever been disqualified from interpreting in a court or administrative Yes/No proceeding? If Yes, please explain: _______ B. Have you ever been convicted of a felony? Yes/No If Yes, please explain: _______ C. Have you ever been convicted of any crime involving theft, fraud, dishonesty, or Yes/No moral turpitude? If Yes, please explain: CONTINUED 3 American LegalNet, Inc. www.FormsWorkFlow.com 12. REFERENCES: Give the names and mailing addresses of three persons, who know you well but are not related to you, who will verify your experience and expertise as an interpreter. NAME MAILING ADDRESS PHONE/EMAIL ADDRESS 13. TRAVEL: How many miles are you willing to travel to do interpretation for a one-day hearing? ___________ Miles 14. OTHER INFORMATION OR EXPERIENCE: Provide any other information on your experience or education that would be useful in assessing your competence as a court interpreter. OATH: Subject to penalty of perjury, I swear or affirm that: (1) The information I have provided in this application is true and correct; (2) I have read, understand, and will abide by Iowa's Code of Professional Conduct for Judicial Branch Interpreters, Iowa Court Rules, Chapter 48. ________________________________________ Applicant's Signature Sworn to and subscribed before me this _____ day of _______________, 20 ____. (Notary Seal) ________________________________________ Notary Public for State of _________________________________ After completing this form, mail it along with a check for $25 made payable to "Court Interpreter Program" to: Office of Professional Regulation Court Interpreter Program 1111 E. Court Ave. Des Moines, IA 50319 4 American LegalNet, Inc. www.FormsWorkFlow.com STATE OF IOWA Criminal History Record Check Request Form DCI Account Number: Office of Professional Regulation (if applicable) To: Iowa Division of Criminal Investigation Support Operations Bureau, 1st Floor 215 E. 7th Street Des Moines, Iowa 50319 (515) 725-6066 (515) 725-6080 Fax From: Office of Professional Regulation Judicial Branch Building 1111 E. Court Avenue Des Moines, IA 50319 515.281.8430 Phone: Fax: 515.725.8032 I am requesting an Iowa Criminal History Record Check on: Last Name (mandatory) First Name (mandatory) Middle Name (recommended) Date of Birth (mandatory) Gender (mandatory) Social Security Number (recommended) Male Female Waiver Information: Without a signed waiver from the subject of the request, a complete criminal history record may not be releasable, per Code of Iowa, Chapter 692.2. For complete criminal history record information, as allowed by law, always obtain a waiver signature from the subject of the request. Waiver Release: I hereby give permission for the above requesting official to conduct an Iowa criminal history record check with the Division of Criminal Investigation (DCI). Any criminal history data concerning me that is maintained by the DCI may be released as allowed by law. Waiver Signature: ___________________________________________________________________________ Iowa Criminal History Record Check Results As of ___________________, a search of the provided name and date of birth revealed: (DCI use only) No Iowa Criminal History Record found with DCI Iowa Criminal History Record attached, DCI #______________ DCI initials______________ DCI-77 (08/25/10) American LegalNet, Inc. www.FormsWorkFlow.com