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									                                           Colorado Court Interpreter Program

                                               AGENCY
                                          INFORMATION FORM

In accordance with the Court Interpreter Program’s Language Interpreter Vendor Qualification Approval Process,
agencies interested in providing interpreters for the Colorado State Courts must complete and submit this form. In
addition, agencies must submit the Language Interpreter Qualification Information Form for each interpreter who will
be providing services to the Colorado Judicial Department.
Please fill out the form carefully and complete all entries as appropriate. To enter data electronically, tab between fields
for easier use. If additional space is needed, please use the Additional Information section on page 4.


  Agency’s Profile
  Agency name

  Agency owner name                                                  Business address

  Primary contact name
                                                                     City
  Secondary contact name
                                                                     State                          Zip Code
  Business phone #
                                                                     Primary email
  Secondary phone #
                                                                     Secondary email
  Fax #
                                                                     Website
  Other phone #



  Language Information
  Language combination(s) in which the interpreters working through the agency work (for example:”Italian<>English”)




  Colorado Court Interpreter Program: Agency Information Form                                                          1|P a g e
    Area of Service that the Agency Covers
    Agencies seeking to provide interpreters for the Colorado State Courts must indicate the areas of the state in which they can
    provide interpreter coverage. This is not a guarantee of work in each region, but rather an indication of interpreter
    availability if requested. Agencies may refer to the map of judicial districts below or consult the Judicial Branch’s website at
    http://www.courts.state.co.us/Courts/Index.cfm. Additional information may be provided on page 4.
    Please check all that apply. You may check either the region or specific areas within that region for which the agency could
    provide coverage. If you select the “Statewide” option, it is not necessary to select any of the individual regions.
        Statewide
        Denver Metro Area Region                                                Central Region
           Denver              (2nd Judicial District)                            Alamosa*                    (12th Judicial District)
           Adams County*       (17nd Judicial District)                           Clear Creek County*         (5th Judicial District)
            Arapahoe County*          (18th Judicial District)                    Fremont County*             (11th Judicial District)
            Boulder                   (20th Judicial District)                  Southwestern Region
            Jefferson County*         (1st Judicial District)                      La Plata County*           (6th Judicial District)
        Northwestern Region                                                        Montezuma County*          (22nd Judicial District)
           Garfield County*           (9th Judicial District)                      Montrose*                  (7th Judicial District)
           Mesa County                (21st Judicial District)                  Southeastern Region
           Routt County*              (14th Judicial District)                     El Paso County*            (4th Judicial District)
        Northeastern Region                                                        Las Animas County*         (3rd Judicial District)
           Larimer County*            (8th Judicial District)                      Otero County*              (16th Judicial District)
           Morgan County*             (13th Judicial District)                     Prowers County*            (15th Judicial District)
           Weld County                (19th Judicial District)                     Pueblo                     (10th Judicial District)
*     Indicates the primary location in a Judicial District with multiple courts. Mark this district even if you only want to work in one
      specific court location within that district.




    Colorado Court Interpreter Program: Agency Information Form                                                               2|P a g e
                                         COLORADO JUDICIAL DEPARTMENT
                             AUTHORIZATION AND CONSENT FOR RELEASE OF INFORMATION -
                                     LANGUAGE AND ASL COURT INTERPRETERS
Full Legal Name (Print):
                                    First                                       Middle                          Last
Names Also Known As (“AKA’s”) including Maiden Name, All Former Last Names, Nicknames, etc. (Note: Omitting AKA’s may
result in disqualification for contract work) :
Position Sought:
   Language Interpreter Agency Owner

Date of Birth:                                            Social Security Number:                                      Gender:       Male        Female
Home addresses during the past five years, including current:


Have you ever been convicted or adjudicated of a felony; a misdemeanor; or any traffic or petty offense involving
drugs or alcohol? Conviction means a finding of guilt by a judge or jury; entering a plea of guilty or no contest (nolo
contendre) or entering into a deferred sentence or adjudication where the sentence is still deferred or the case is still
pending. Yes     No
Do you have any criminal or juvenile charges currently pending, including felonies; misdemeanors; or any
traffic/petty offenses where alcohol or drugs are alleged to be involved? Yes No
If you selected yes to either criminal history question above, please explain such criminal history, including the
date, charge(s) filed, disposition and court location and any mitigating information, if any, regarding the
circumstances.



I hereby authorize and consent to a criminal background check and to the release of any and all information held by law enforcement agencies, including
without limitation, arrest records, incident reports and criminal investigation reports, to the Colorado Judicial Department to verify my suitability to
perform services for the Colorado Judicial Department as an independent contractor.
I hereby authorize the release of any and all persons, entities, agencies and organizations, individually and collectively, from liability for damages of
whatever kind relating to or arising out of any release of information, including records, statements and opinions, as a result of this authorization.
A photocopy of this authorization shall be as valid as the original for one year from the date it is signed.
I understand that an award of a contract will be based upon the results of this investigation and that any award and/or contract is conditioned on my
receiving, in the Judicial Department’s discretion, a satisfactory background investigation. I further understand that refusal to sign this form may result in
the award and/or contract being withheld or withdrawn.
I have read, understand and consent to the above statements.



Signature                                                                                       Date


Authorized Witness Signature* (Managing Interpreter, Program Manager or Designee)               Date
*Forms that are sent by mail, fax or email without an authorized witness signature must be notarized using the section below.
State of Colorado                                               )
                                                                ) ss:
County of _         ___________________________________         )
This document was signed and acknowledged before me on this day,                           20            .
                                                                          (month / day)         (year)


(Notary’s Seal or Stamp)                                          Signature: Notary Public in and for the State of Colorado
Colorado Court Interpreter Program: Agency Information Form                                                                                  3|P a g e
Additional Information




I hereby certify that all statements, information and documents provided with this form are true, complete and correct to
the best of my knowledge and are made in good faith. I understand that any false statements, omissions, or
misrepresentations that I indicate on this form or provide in any interview process or related correspondence may
disqualify me for consideration. Should an investigation at any time disclose any falsification, omission, or
misrepresentation as to the same, said disclosure may be grounds for immediate suspension of services.

Signature of Agency Owner:                                                                Date:
                             Electronic signatures are authorized and considered valid.

                             Completed forms must be sent by mail, email or fax to:
 FY2011 Language Interpreters  Colorado Judicial Department  101 W. Colfax Ave., Suite 500  Denver, CO 80202
                         Fax: 303.837.2358  Email: marci.sannes@judicial.state.co.us

Colorado Court Interpreter Program: Agency Information Form                                                 4|P a g e

								
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