Division for Rehabilitation Services Office for Deaf and Hard of Hearing Services Language Proficiency Tests

DARS/DHHS will use the information provided in this form to request a criminal history conviction check from the Texas Department of Public Safety.

Applicant Information

Applicant’s name:

Birth date:

Last four digits of Social Security number:

Address:

City:

State:

ZIP code:

County:

Contact Information

Daytime phone number: (   )

Alternate phone number: (   )

Email address:

Mobile number (optional): (   )

Video phone number:     VP 100/200        DLink or webcam

Statistical Information

Gender (enter X to select one):      Male      Female

Auditory status (enter X to select one):

Deaf

Hard of Hearing

Hearing

Ethnicity (enter X to select one):

African-American

Asian

Hispanic

Native American

Pacific Islander

White

Other:

Qualifying Questions

1. Are you at least 18 years old?                                                               Yes     No

2. Have you graduated from high school or passed the GED?              Yes     No

Language Proficiency Tests

Enter X to select one:

Test of English Proficiency

Enclose fee: $75

Test of Spanish Proficiency

Fee: TBD

Test of American Sign Language Proficiency

Fee: TBD

Preferred Testing Site
Enter X to select one:
I wish to take my test at the UT K–16 Testing Center, 3001 Lake Austin Blvd., Suite 1.202, Austin, Texas.
I wish to take my test at the facility listed below: Exams must be supervised at an approved testing center at a college or university. Other locations must be approved in advance by the testing center at the UT K–16 Testing Center. Please include the following information in your request. Failure to make prior arrangements may result in the rejection of your exam application.
Institution:			Contact person:
Address:		City:		State:	ZIP code:
Telephone: (   )	Fax number: (   )		Contact person’s email:
Proof of Identification
You must present a current photo ID to take a test. If you do not have a photo ID, call the testing center at (512) 232-5000 and request that an ID form be sent to you. The form requires the signature of a notary public. Allow at least one week for processing of the ID form.
Special Accommodations
If you have a physical or learning disability, we will make every effort to accommodate your needs with special testing arrangements. However, in order to serve you best, we need to receive proper documentation describing the nature of your disability and suitable accommodations. If you have not yet submitted this documentation to our office, please enclose it with this form.
Fee and Submittal Instructions
Make check or money order payable to DARS/DHHS.
Mail this form and the fee to DARS/DHHS, P.O. Box 12306, Austin, Texas 78711.
Code of Professional Conduct
Tenets Interpreters adhere to standards of confidential communication. Interpreters possess the professional skills and knowledge required for the specific interpreting situation. Interpreters conduct themselves in a manner appropriate to the specific interpreting situation.  Interpreters demonstrate respect for consumers. Interpreters demonstrate respect for colleagues, interns, and students of the profession. Interpreters maintain ethical business practices. Interpreters engage in professional development. The full version of the Code of Professional Conduct may be obtained from the DHHS office or the RID-NAD Web site at www.rid.org.
I attest that all information provided herein this application is accurate and true and agree to abide by the Code of Professional Conduct. I understand that my certificate is subject to suspension, revocation, or cancellation in accordance with rules established by the Board for Evaluation of Interpreters.
Applicant’s signature: X			Date:
Office for Deaf and Hard of Hearing Services 4900 North Lamar, Suite 2169, Austin, Texas 78751 P.O. Box 12306, Austin, Texas 78711 (512) 407-3250 Voice or (512) 407-3251 TTY www.dars.state.tx.us/dhhs