(562) 860-2451 ext. 2335
(562) 467-5006 (FAX)
(562) 274-7164 (VP)
LA/DSPS Building
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Monday - Thursday: 8 am - 5 pm
Friday: 8 am - 12 pm
Communication Services Form (Student Request)
Please fill out this form completely. Each request must be filled-out separately(only one request per form).
Your Name:
Your E-mail Address:
Telephone:
Please select the appropriate service.
Need service for a ONE-TIME assignment
Need service for a new class for the semester
Cancel service ONE-TIME (list reason below in the comments section)
Cancel service for the whole semester (list reason below in comments section)
Interpreter/RTC No-Show (List name of interpreter below in comments section)
Please select your communication preference
Sign Language Interpreter
Real-Time Captionist
Assistive Listening Device
Please fill in ALL information in this section.
Please type in the class title or type of appointment: (Counseling, class etc.)
Select the appropriate day service will be needed or canceled
Mon Tue Wed Th Fri Sat Sun
Date of class/appt.:
Start Time: AM PM
End Time: AM PM
Course Ticket Number:
Course description:
Location of class/appointment (building and room):
Name of instructor/person your class/appointment is with:
Comments/Additional Information:
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