Please print this application and fill it out manually. When done, please mail it to DBSC.
Last Name First Name Middle
Inital
Address
City State Zip
( ) V
/ TTY
Home Phone
Home E-mail
( ) V
/ TTY
Work Phone
Work E-mail
Is calling / e-mailing you at work
okay?
Calling ____Yes ____
No E-mailing ____ Yes ____ No
E-mail Pager
( ) ( )
Cell Phone Number Pager
Which phone number is best to
contact you if a DB Client needs to cancel an appointment?
Do you have a car? ____ Yes ____ No
I am interested in:
____ “Paid SSP”
____ “Ongoing Volunteer”
____ “One-Time Only”
____ “Sub”
Reference: Either Deaf-Blind person, sign language
teacher, SSP, or interpreter:
Name:
Address or Phone:
Email address:
Why
do you want to work as an SSP?
________________________________________________________
________________________________________________________
________________________________________________________
Background
with Sign Language:
________________________________________________________
________________________________________________________
________________________________________________________
Background
with Deaf-Blindness:
________________________________________________________
________________________________________________________
________________________________________________________
Hobbies: _______________________________________________
Criminal Background
It is required by law for DBSC to
check your criminal background by Washington State Patrol (WSP) on yearly
basis. I agree to submit to criminal
background check by WSP.
Signature: Date:
*Legal Name: First
Name Middle Initial Last Name
*Date of Birth:
*It is required to enter your legal
name and date of your birth for criminal background.
Please mail this application to:
Attn: SSP Program
162018th Avenue,