PC Renew Computer Request Application - Please answer all questions. If you are not making application through an agency or charity go to the name line in the information section and answer all questions.
Date
*
Agency Information ( Fill in all)
Name of Agency
Authorized Agency Representative
Agency Phone number with Extension
Name of Applicant (If individual start here)
Address
*
Apartment
City
*
State
*
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
*
Phone Work
Phone Home
*
Cell Phone
e-mail address
SS #
*
Age
*
Occupation
*
Annual Family Income
*
Do you own a computer
*
yes
no
If yes, how many
Do you now have internet access?
dial up
Cable
DSL
Fios
Do you know how to operate a computer?
Yes
No
very basic
What will you use this computer for? if more than one click all that apply
School
Word Processing
Family Record Keeping
Internet
Games
Business
Second Computer in House
Other
Please tell us why you should receive a computer?
*
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