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Communications Service Request <br />Fax Form <br />Date: To be determined Time: 3:30 to 5:00 <br />M T W Th F Sat Sun <br />Name ofRequestor: Martha McCarthy Phone #: (714) 647 -5355 <br />Agency Name: City of Santa Ana Fax #: $714) 647 -6930 <br />ASSIGNMENT INFORMATION <br />Deaf Consumer: Jacob Aina (Cit <br />Facility: City Hall, City of Santa Ana <br />Assignment Address: 20 Civic Center Plaza Santa Ana <br />(Street) (City) <br />Personnel Services Department, 5th Floor <br />Cross Street: 6th and Flower Streets <br />Parking:Enter at 6th and Flower (between Civic Center Blvd and <br />Santa Ana Blvd) <br />Nature of Assignment: Provide Interpretive Services at discussion <br />between employee and supervisors <br />Contact Person: Martha McCarthy (714) 647 -5355 <br />BILLING INFORMATION <br />Billing Address: c/o Personnel Services Department M24 <br />City, State, ZIP: 20 Civic Center Plaza Santa Ana, CA 92701 <br />Attention: Martha McCarthy <br />PO # (if applicable) <br />Authorized Signature <br />Today's Date <br />