Community Computer Request Form
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
Neighborhood
Postal Code
Number of family members
Household income
Less than $26,000 Annually
More than $26,000 Annually
Phone Number
*
-
Area Code
-
Phone Number
Items to received
*
1 Monitor
1 Tower
1 Keyboard
1 Mouse
Rate your computer experience
No knowledge
Some knowledge
Advanced knowledge
Referred by
Newsletter
Yes, I would like to receive emails with delivery promotions and news about events.
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