Eipa Registration Renewal Form – Fill Out and Use This PDF

Charges will be added for Non-Sufficient Funds.

____$30.00 for Legislatively Mandated Annual Registration / Renewal Fee. (C3 Account Code 8070)

INSTRUCTIONS:

•Type or print legibly with black or blue ink only. Provide a response to all questions or write “N/A” (Not Applicable).

•Enclose the appropriate renewal fee (no cash) and make payable to “State of Michigan”:

Division on Deaf and Hard of Hearing Attn: EIPA Interpreter Registration/Renewal 201 Washington Sq. Suite 150

Lansing, MI 48913

•Fees are not refundable except for circumstances set forth in the Regulations Governing the Practice of Interpreting as applied to 1982 PA 204, as amended 2007.

•Include all supporting documents as indicated on the checklist. Failure to complete the registration/renewal form in full or omit required documents may cause processing delays.

•Sign and date your renewal form where indicated. Registrations/renewals without a signature will result in delayed registration.

•Keep a copy of your completed registration/renewal form.

•By completing this registration you agree to comply with all rules and regulations that governing the practice of Interpreting as applied to 1982 PA 204, as amended 2007. Additional information regarding Rules and Regulations can be found on our website (www.mcdc-dodhh.org) upon completion of the rules promulgation process.

•Once the registration/renewal information has been received and processed, your credentials will be updated online and a new EIPA interpreter certification card will be sent to you.

SECTION I: PERSONAL INFORMATION You are responsible for updating your contact information on line after your initial registration. Failure to update contact changes and subsequent failure to receive information does not exempt you from any liability in relationship to the Michigan Deaf Persons’ Interpreters Act (PA 204 of 1982, amended in 2007).

I am currently listed in the Online Interpreter Directory.

I need a password and ID # to access my online interpreter registration .

NAME (Last, First, Middle Initial):		EMAIL ADDRESS:
ADDRESS (Street Number and Street Name):		CITY:	STATE:	ZIP CODE:
HOME PHONE (With Area Code):		BUSINESS PHONE:
CELL OR TEXT NUMBER:		VIDEOPHONE:
SECTION II: RENEWAL OR FIRST-TIME REGISTRATION	Mark one of the two boxes below and complete
additional information as needed for each category.

SECTION III: RECORD OF ANNUAL PROFESSIONAL DEVELOPMENT ACTIVITIES (20 HOURS REQUIRED ANNUALLY AFTER INITIAL REGISTRATION) Please attach additional paper if needed to complete listing of ALL activities.

SECTION IV: DEMOGRAPHIC INFORMATION:

Iam currently an educational interpreter at_______________________________________________(Name of School). Operating under the school district of___________________________________________________(District)

I am an employee of the school district.

I am a contractor. The contract is under the following company:

Name of Company_____________________________________________________________________________

Company contact______________________________________________________________________________

CHECKLIST

__ Completed registration/renewal form. __ Payment made out to “State of Michigan”

__ Letter from Boys Town showing level, mode, and score.

__ Letter from Boys Town showing passed the EIPA written test if applicable.

__ Certificate showing activity approved for CEU/BEI units or pre-approved signed documentation

Print Name: ____________________________________________________________

Signature of Applicant: ________________________________	Date: ___________
Mail registration/renewal form, payment, and supporting documentation to:
Division on Deaf and Hard of Hearing
EIPA Interpreter Registration/Renewal
201 N. Washington Square, Suite 150
Lansing, MI 48913	(517) 335-6004/(877)499-6232

DELEG is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.

8/11/2010