Housing Kiosk Request
Today's Date:
-
Month
-
Day
Year
Date
Name of Organization:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Name:
First Name
Last Name
Contact E-mail:
example@example.com
Contact Phone Number:
Please enter a valid phone number.
Organization Type:
Court
Legal Services Provider
Shelter for Survivors of Domestic Violence
Homeless Shelter
Food Pantry
Library
Community Center
Medical Provider
Other
If other, please describe.
Organization Type
Does your location have internet access (either ethernet or secure wifi)?
Yes
No
Could your location make available a surface that is approximately 36 x 36 inches that is accessible by wheelchair?
Yes
No
If the point person for this location is someone different than the person listed above, please share their name here.
Name Point Person
Point person email (if different from above).
example@example.com
Type of kiosk your organization is interested in hosting:
Desktop
Freestanding
Either desktop or freestanding
How did you hear about this project?
This project will allow us to provide a small number of enclosed rooms for private access to kiosks. Would you be interested in learning more?
Yes
No
Other Information (not required):
Submit
Should be Empty: