LFC Application

Date

Hour MinutesAM/PM Option

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

What Organization do you work for? If unemployed enter NA.*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Why do you need a computer?*

Qualifying Information*

ID*

Qualification*

I hereby give permission to Loaves Fishes and Computers to use my first name, and first names of family members and photographic likeness in all forms and media for advertising, to use funders, and donors, to show LFC is helping our community.*

YesNo

By signing this agreement, I agree to meet at least one of the above qualifiers.

I will not sell or trade computers and accompanying equipment for the lifetime of the computer for any financial gain. Suppose the computer system is no longer needed. In that case, I will return the computer system to Loaves Fishes and Computers Inc. or transfer it to another qualifying person or family member.

Please Note: Your computer purchase has a WARRANTY; please read your receipt for additional information or ask a salesperson. Additional repair costs made outside LFC (while under warranty) will not be refunded.

Please be aware that the computer you are receiving is used, and therefore, it is highly advised to always backup your most important data to an external drive (thumb drive, CD, etc.). We are not liable for data loss due to failing equipment.

Initial below to state that you read and understood the terms and conditions listed above. *

Initial Here

Are you a senior 60 years or older?*

YesNo

Application

AAA Senior Survey

Application Survey