COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.The Industrial Commission of Ohio Columbus, Ohio 43215-2233JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)Interpretive Services Request FormThe Industrial Commission will provide interpretive services to injured workers or employers who are hearing impaired or who require a foreign language interpreter at hearings and medical examinations at no charge.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE PEOPLE OF THE STATE OF NEW YORK TOThe Interpreter Coordinator may be contacted in the following ways: Print and mail this form to: The Industrial Commission of Ohio, Attn: Interpreter Services Coordinator, 30 W. Spring St. 5th floor, Columbus, Ohio 43215-2233Telephone: (614) 752-4036 or 1-800-521-2691TDD number: 1-800-686-1589Fax: (614) 728-7004GREETINGS:E-mail the following information to: mailto:AskIC@ic.state.oh.usWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofShould the need for this service change, please contact the Industrial Commission 24 hours prior to the hearing.o'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.Please type or print clearly and answer all questions to the best of your ability. Your cooperation in completing this form will aid in processing this request Injured Worker's name Date of birth Address City State Zip code Telephone number Claim number Social Security Number Date of injury Date service is required Location service is to be performed Type of service (i.e., sign language or the specific foreign language needed) OIC 2005, one of the Justices of theCourt in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)Attorney(s) forOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:IC-INT Justice for the workplaceMobile Tel. No.:An Equal Opportunity Employer And Service ProviderAmerican LegalNet, Inc. www.USCourtForms.com
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