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
Signature of Applicant
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please verify that you are human
For Internal Use Only
Date decided:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Decided by:
Date distributed:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature of coordinating staff member:
Should be Empty: