QUESTIONNAIRE FOR PROS PECTIVE INTERPRETERS Full Name: Date of Birth Social Security/Taxpayer ID Number Address Telephone Number: Day Evening Fax Pager Cellular E-mail Education (all schools above elementary): School Location Year(s) Attended DegreeDo you have any particular training , certification or other credentials as an interpreter? yes no (if yes, describe;list language or interpreting courses taken, name/ location of school, dates attended, certificates awarded, and name ofagency or organization granting certification) Linguistic ability (for each language you wish to be considered for - use additional sheets, if necessary): LANGUAGE Dialect (if any) Read Write Speak Interpret Level of ProficiencyIn what country were you born? In what country were you raised? How many years have you lived in the United States? Are you a U.S. citizen? yes no What is your native language? <<<<<<<<<********>>>>>>>>>>>>> 2If not English, how did you learn English? If not the language you interpret, how did you learn the language ? Do you belong to any associations of professional interpreters? yes no (if yes, specify) Can you interpret simultaneously? yes no Can you interpret consecutively? yes no Do you work full-time or part-time as an interpreter? yes no If no what is your primary employment? Have you ever worked as a conference or seminar interpreter ( staff or free-lance) for the Office of Language Services ofthe United States Department of State, or the United Nations, or related agencies for which examinations are a conditionof employment? yes no If yes please specify below. Use back of sheet if more space is needed. Have you interpreted in FEDERAL court before? yes no How many times? In criminal court? yes no In this district? yes no Have you interpreted in any STATE/ LOCAL court before? yes no How many times? In criminal court? yes no List the courts in which you have interpreted Have you interpreted in any other court or administrative proceedings before? yes no How many times? List the courts or administrative proceedings in which you have interpreted Have you read and understood the Code of Professional Responsibility for Court Interpreters? yes no Please include a current resume and three (3) written recommendations which speak to your character and ability tointerpret in the language(s) for which are applying. I hereby certify that the above information is true and correct and I wish to be considered for inclusion on the InterpreterServices Roster used to make assignments for court interpreters services in the United States District Court for the EasternDistrict of Pennsylvania. Date Signature NOTE CONCERNING TAXPAYER IDENTIFYING NUMBER You are hereby notified, pursuant to the Privacy Act of 1974, Public Law No. 93-579, Section 7(b), 88 Stat. 1996, 1909, that disclosure of your social security number is mandatory. The authority for the solicitation of your number is IRC, Sections 6041, 6109, and 26 CFR, Section 301.6109-1 (1978). The Director of the Administrative Office of the United States Courts will use your social security number to make information returns to the Secretary of the Treasury.