Housing Kiosk Request
Name of Organization:
Street Address Line 2
State / Province
Postal / Zip Code
Contact Phone Number:
Please enter a valid phone number.
Legal Services Provider
Shelter for Survivors of Domestic Violence
If other, please describe.
Does your location have internet access (either ethernet or secure wifi)?
Could your location make available a surface that is approximately 36 x 36 inches that is accessible by wheelchair?
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).
Type of kiosk your organization is interested in hosting:
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?
Other Information (not required):
Should be Empty: