Computers for Community - Device Request
Please submit this form to gather the information to prepare your tax receipt.
Submission Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
*
First Name
Last Name
Email
example@example.com
Phone Number
*
A cell phone number is required to set up and access a Google account on Chromebooks. Google uses this number for two-factor authentication to help keep the account secure.
Format: (000) 000-0000.
City
Zip Code
Please select the type of device you are requesting
Laptop
Desktop
Monitor
Other
Do you have reliable access to internet/WiFi at home?
Device details
Please select your preferred language
English
Spanish
Which race or ethnicity best describes you?
White
Hispanic / Latino
Other
Age
Under 18
18 to 34
35 to 44
Older
Gender: How do you identify?
Male
Female
Non-binary
Back
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Household size
Emplyment Status
Unemployed
Full-time
Part-time
Self-employed
Education Level
No school
Highschool graduate
Degree graduate
Intende use for the computer
Do you currently own any other computer devices?
What is your main goal in receiving this computer?
Would you be interested in volunteering or contributing to this program in the future?
How did you hear about this program?
If you are requesting the device on behalf of someone else, please explain below
Submit
Should be Empty: