Technology Assistance Application

1
Full Name* This field is required.Please Fill Out Full Legal Name
First Name
Middle Name
Last Name
2
Current Address* This field is required.Please Fill Out Your Current Address. We Need Information to Ship You Computer.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Email Address* This field is required.Please Use your own Email Address.
Email Verified
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Please check your mailbox and paste the code below to complete verification
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4
Phone Number* This field is required.We Need Your Phone Number To Contact You. We Will Contact You if your approved or not.
Area Code
Phone Number
5
Source of Income.* This field is required.We Need To Verify Your Income. If You Have a Job, SSD, Unemployment, or SNAP, We Need verification if you will allow us to.
I Have A Job.
Social Security Disability
Unemployment
Snap Benefits
6
Amount Income* This field is required.Your Take Home Pay After Taxes.
7
Place Of Employment or Social Work Name: * Work Phone/ Social Worker
8
We Can Contact Your Employer / Social Worker to Verify your Income?* This field is required.the questions we ask your employer are: is he/she employed here and for how long. and about how much income.
Yes
No
9
Do You Currently Have a Computer That Needs Repair or Service?if you have a computer that needs repair, we can help you with that process. we offer tech support services.
Yes
No
10
If We Donate / Grant you a Computer, what will you be using the computer for? (School, Work, Job Searching.)please explain your plans with the computer, how your going to use it, if its for your child or if its for school work. it gives us an idea what kind of programs you might use on the computer. and you can tell us what programs you have already and we can install them for you.
11
Do You Need Assistance Learning Windows 7/10 O/S or Microsoft Office programs? We Can Assist You With This Training.we offer free computer training. if you need help with your computer, please call or email us to setup remote training or in person.
Yes
No
12
Terms and Conditions* This field is required.Electronic Donation Services Donation Policy To receive the computer, you must fit certain requirement, once you receive the computer there are some rules that are important to follow. 1. You cannot sell / pawn any devices. All devices have been registered to our Nonprofit Group and cannot be sold to a pawn store; they will see it in their system as a red flag. 2. If you no longer need the device, you must return it to us. 3. We provide you with our Tech Support Program. If you have issues with your PC please contact us and we will help you fix it, please to don’t open the computer or try to fix it yourself. We will fix it for you. We have Anti-Tamper stickers on the devices. 4. We want to help you at any time. If you have a problem, please email us at Electronicdonationservices@gmail.com
13
Signature
14
Please verify that you are human* This field is required.
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