EQUIPMENT GRANT REQUEST

EQUIPMENT GRANT REQUEST
FORM
Name of individual:*
Mailing address:*
Phone number:*
E mail address:*
example@example.com
Applications may be sent to contact@freeitathens.orgor P.O. Box 81931 Athens, GA 30608.Incomplete applications will not be considered.
⦁ Please describe your grant request by listing the specific items you need (e.g. one desktop computer with a monitor, mouse, keyboard).*
Describe how granted equipment will help your current situation*
How much can you budget toward this equipment? Donations are appreciated.*
Acknowledgment and Affirmation of Grant Policies By signing below, I (Printed Name) Name on this date understand and agree to comply with possible periodic reviews of equipment usage and implementation as well as agree to allow Free IT Athens, Inc. to publicize granting of equipment and/or how granted equipment is to be used. Furthermore, I understand that this application is for review by Free IT Athens, Inc. and in no way a guarantee of grant acceptance.
I agree*

YesNo
Signature of Applicant*

Clear
Date*

MonthDayYear
Date
Please verify that you are human*
For Internal Use Only

ApprovedDenied
Date decided:

MonthDayYear
Date
Decided by:
Date distributed:

MonthDayYear
Date
Signature of coordinating staff member:

Clear
Should be Empty: