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 *

Zip Code *

Phone Work

Phone Home *

Cell Phone

e-mail address

SS # *

Age *

Occupation *

Annual Family Income *

Do you own a computer *yesno

If yes, how many

Do you now have internet access?dial upCableDSLFios

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

Other

Please tell us why you should receive a computer? *