<p>DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Public Health F-02036 (02/2017)</p><p>DISASTER RESPONSE INTERPRETER TRAINING APPLICATION Great Wolf Lodge, Wisconsin Dells Saturday, April 29, 2017 8:00 a.m. – 5:00 p.m. Sunday, April 30, 2017 8:00 a.m. – 12:00 p.m.</p><p>FAX or MAIL the application by March 27, 2017 to: Office for the Deaf and Hard of Hearing Attn: Carly Bieri 1 W. Wilson Street, P.O. Box 2659 Madison, WI 53701-2659 Fax: 608-264-9899 Your Full Name Phone Number</p><p>Mailing Address City State Zip Code WI Email Address</p><p>Freelance Are you currently employed through an Interpreter Agency Yes No Yes No If yes, please list name: </p><p>Applicant Experience and Information Interpreting Credentials RID Member Number</p><p>Wisconsin Sign Language Interpreter License Number Number of Years Interpreting #150 or #151 Types of Interpreting Educational Legal/Law Enforcement Disaster Medical Media Community/Social Services</p><p>Other, Please list: Other Relevant Experience/Training</p><p>RIDCMP 0.8 Professional Studies, Content Level: Some, offered through WisRID an RID CEUs approved RID CMP sponsor.</p><p>*Please attach your resume and a letter of interest.</p><p>I certify that the above is true and correct. SIGNATURE – Applicant Date Signed FAX OR MAIL NO LATER THAN FRIDAY, MARCH 27. 2017.</p>