A service of the Hamilton Multicultural Services Trust Providing Solutions in over 50 languages Phone (during office hours): (07) 853 0480 | 24 Hour phone: (027) 479 2419 Email: firstname.lastname@example.org | Fax: (07) 838 2195 7 Decypher About Us Interpreting Translating Languages Contact Interpreter Request Form Please complete the below form Agency DetailsName of Agency*Contact name* First Last Contact phone number*Contact fax numberEmail address* Invoicing DetailsPostal Address (for invoice)* Street Address Address Line 2 City ZIP / Postal Code AttentionReference/purchase order numberAssignment DetailsDate Required* Start Time* : HH MM AM PM Finish Time* : HH MM AM PM Location of Assignment* Street Address Address Line 2 City Non-English speakers full name* First Last Language spoken*Gender*MaleFemaleSpecific gender of Interpreter required*MaleFemaleEitherService Required*Face to faceTelephone ServiceNHI (if relevant)Please enter your National Health Index numberDoes the Interpreter need to confirm the appointment with the non-English speaker?*YesNoIf so, what is the non-English speaker’s phone number(s)Notes or other relevant informationTERMS AND CONDITIONS* Minimum charge – there will be a minimum charge that relates to the initial duration of time requested. Any additional time will be charged at Decypher’s standard rates. Payment is due within 14 days. * Cancellation – any cancellation within 24 hours of the confirmed commencement time of the assignment will incur a cancellation fee. Please ensure cancellation is notified to Decypher’s 24 hour phone 027 479 2419 outside of office hours.