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. We need an e-mail address filled in by the person

Date *

Agency Information ( Fill in all)

Name of Agency

Authorized Agency Representative

Agency Phone number with Extension

e-mail address of the person who made out this application *

Do you know how to operate a computer? YesNo very basic

Other

Please tell us why you should receive a computer? *

Have you or anyone in your family ever received a computer from us before * YesNo

If yes when?

E-mail Address to respond to this request. *