UMOJA Computer Request Form

Name*

First NameLast Name

Email*

example@example.com

Address*

Street Address

Street Address Line 2

City

Postal Code

Number of family members

Household income

Less than $26,000 AnnuallyMore than $26,000 Annually

Phone Number*

Area CodePhone Number

Items to received*

1 Monitor1 Tower1 Keyboard1 Mouse

Rate your computer experience

No knowledgeSome knowledgeAdvanced knowledge

Referred by

Newsletter

Yes, I would like to receive emails with delivery promotions and news about events.

Community Computer Request Form