Language Services Associates

	English • Español

Please complete the form below. Try to fill in as many fields as you can. Items marked with a red * are required.

1. General Information

Identification Information

First Name: *

Last Name: *

Address:

City:

State (if applicable):

Zip Code:

Contact Information

Primary Phone: *

Home Phone:

Business Phone:

Mobile Phone:

E-Mail Address: *

Availability Date:
Date Format: MM/DD/YYYY

Language Skills

Country of Origin:

Skills:

Certification:

Occupation:

Previous Interpretation Training: Yes No

Languages Spoken

Primary:

Second:

Third:

Fourth:

Fifth:

Sixth:

Additional Information

Gender: Female Male

Date of Birth:
Date Format: MM/DD/YYYY

Residency Status:

Areas of Interest:

Education:

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2. Direct Language Exposure

In what countries have you resided?

Country 1:

From:
Date Format: MM/DD/YYYY

To:
Date Format: MM/DD/YYYY

Activities (childhood, school, travel, work, etc.):

Country 2:

From:
Date Format: MM/DD/YYYY

To:
Date Format: MM/DD/YYYY

Activities (childhood, school, travel, work, etc.):

Country 3:

From:
Date Format: MM/DD/YYYY

To:
Date Format: MM/DD/YYYY

Activities (childhood, school, travel, work, etc.):

Additional countries, remarks:

3. Reference Works

List the dictionaries you own (title, publisher, year of publication):

Do you have any other language references, such as a thesaurus, style manual, grammar book, etc.?
If so, name them:

Where would you go for additional references if you needed to look up something you could
not find in your own library?

4. Language Acquisition - Part 1

General Information

Degree of fluency in English (1-10; 10=fluent)

How did you learn it?

What is your native language or mother tongue (the one you learned first)?

What do you consider your dominant language at present (the one you feel most comfortable
speaking in most situations)?

What languages do you use actively (speak, read, write fluently)?

Language 1

Name/Dialect:

Country where it is spoken:

Fluency (1-10):

Language 2

Name/Dialect:

Country where it is spoken:

Fluency (1-10):

Language 3

Name/Dialect:

Country where it is spoken:

Fluency (1-10):

What language(s) do you have passive knowledge of (can read and understand some, may have studied in the past, but do not use it actively at present)?

5. Language Acquisition - Part 2

Indicate how you acquired each of your languages:

Language 1:

Acquired at age:

Education in this language (check all that apply; that is, if you went to both primary school and secondary school in that language, check both): Primary (ages 6-12)
Secondary (ages 13-18)
University (age 18+)
Other (specify below)

Other education:

Other activities carried out in this language (check all that apply): Interaction with family at home
Travel and tourism
Socializing with friends
Entertainment (TV, radio, movies, music, theater)

Type of reading you currently do regularly in this language (check all that apply; mark none if you don't read very often in this language): Newspaper
Magazine
Professional journals and publications
Literature
Children's stories
None
Other (specify below)

6. Professional Experience

Membership in professional organizations:

Have you received any training in cultural competence? If so, when and where?

Year you began interpreting professionally:

Please list other agencies/organizations for whom you interpret professionally:

Are you an Employee of any of the above listed Agencies for whom you interpret professionally? Yes No

Types of interpreting you do:

Have you ever worked with headsets? Yes No

Interpreter booths? Yes No

Have you ever done telephonic interpreting? Yes No

Are you presently? Yes No

Please name the agencies for which you perform telephonic interpreting:

Have you interpreted for worker's compensation proceedings? Yes No

Have you ever interpreted in front of groups (more than 50 people)? Yes No

Have you interpreted for med-legal appointments, (ME/AME/IME)? Yes No

Have you interpreted in depositions? Yes No

In trials? Yes No

In which courts have you worked in the last year?

Highest court:

Have you interpreted for mental health patients? Yes No

Children? Yes No

Please list any areas of specialized terminologies in which you have expertise:

Do you have any non-compensated experience as a volunteer? Yes No

Please use this section to mention any other interpreting experience you have that does not fit in elsewhere
e.g. charitable, family, educational:

Please mention any awards, publications or accomplishments not already listed:

Complete your application.

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