UMOJA Computer Request Form

Community Computer Request Form
Name *

First Name Last 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 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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Community Computer Request Form