Computers for Community - Request a Device
Please submit this form to be added to the waitlist for a refurbished device. We require your name, email and zip code. All other questions are optional.
Please verify that you are human
*
Name
*
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
City
*
Zip code
*
Please select the type of device(s) you are requesting. If you are requesting multiple devices, please specify in 'Other' e.g. 2 x Monitors
*
Laptop
Desktop PC
Monitor
Unsure - I need advice
Other (please specify)
Do you have reliable access to internet/Wi-Fi at home?
Yes
No
Please select your preferred language(s):
English
Spanish
Russian
Ukraine
Chinese
Vietnamese
Other (please specify)
Which race or ethnicity best describes you?
American Indian / Alaskan Native
Asian / Pacific Islander
Black / African American
Hispanic / Latino
White / Caucasian
Multiple ethnicity / Other (please specify)
Age
Under 18
18-24
25-34
35-44
45-54
55-64
65-74
75 and older
Gender: How do you identify?
Female
Male
Prefer not to say
Prefer to self-describe (please specify)
Marital status
Married
Single
Married with kids
Single with kids
Household size
1
2
3
4
5
6
7 or more
Employment status
Full-time
Part-time
Self-employed
Unemployed
Student
Retired
Prefer not to say
Other (please specify)
Education level
K-12
Highschool graduate
GED
Attending college
College graduate
Intended use for the computer?
Work
School
Personal
Other
Do you currently own any other computing devices?
Yes
No
What is your main goal in receiving this computer?
*
Would you be interested in volunteering or contributing to this program in the future?
Yes
No
How did you hear about this program?
*
If you are requesting the device(s) on behalf of someone else, please explain below:
Additional comments or questions:
Submit
Should be Empty: