Mississippi Registry 
of Interpreters for the Deaf
P.O. Box 219
Raymond, Mississippi 39154-0219


Name: _________________________________________________________

Address: _______________________________________________________

City: ________________________ State: _________ Zip: ________________

Phone: ______________________ E-Mail: ____________________________

Membership Status (check one):
				Regular		______$20
				Associate	______$10
				Student		______$10
				Organization	______$50

Membership dues are due in January each year.  Prorated fees are for new members wishing to join for the remainder of the current year.  Fees are prorated by quarters.


I am (check one) :	_____Deaf	  _____Hard-of-Hearing	_____Hearing


Occupation: _____________________________________________________

Do you interpret?	_____ Yes		_____ No

If yes, what types of interpreting do you do? (Check all that apply)

				______ Community
				______ Religious
				______ Educational
				______ Medical
				______ Legal
				______ Other _____________________________

Have you been screened to evaluate your interpreting skills?  _____ Yes	_____ No

If yes, please indicate Certification/QA Screening Level and date screening was achieved.

				_____ MS QA _____________________________
				_____ NAD   _____________________________
				_____ RID   _____________________________
				_____ Other _____________________________

Your active participation and support in MSRID will be appreciated. 

Which day of the week and time would be more convenient for you to attend MSRID meetings?  

_____________________  


Comments: _____________________________________________________________