D.E.A.F. Inc. - Count On Me Form

	"Count on Me" Form

	Please complete all of the blanks below. We will get back to you as soon as we can.

	Interpreter Name
	Certifications
	Address
	City
	State
	Zip Code

	Social Security # / FEIN#
	Home Phone
	Work Phone
	Cell Phone
	Email Address


	Your Committment:	Please check all that apply
		I wish to participate in D.E.A.F., Inc’s Pro Bono Give-Back Program and add my name to the listserv.
		I occasionally wish to provide paid interpreter services for D.E.A.F., Inc.
		I wish to make a tax-deductible donation to D.E.A.F., Inc. at this time.
		I would like to tutor / mentor an interpreting student.
		I would like to be tutored / mentored at this time.

		D.E.A.F., Inc. 60 General Longstreet Line Newnan, Ga. 30265