Computers for Community - Device Request Form

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 NameLast 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*

LaptopDesktop PCMonitorUnsure - I need adviceOther (please specify)
Do you have reliable access to internet/Wi-Fi at home?*

YesNo
Please select your preferred language(s):*

EnglishSpanishRussianUkraineChineseVietnameseOther (please specify)
Which race or ethnicity best describes you?*

American Indian / Alaskan NativeAsian / Pacific IslanderBlack / African AmericanHispanic / LatinoWhite / CaucasianPrefer not to sayMultiple ethnicity / Other (please specify)
Age*

Under 1818-2425-3435-4445-5455-6465-7475 and olderPrefer not to say
Gender: How do you identify?*

FemaleMalePrefer not to sayPrefer to self-describe (please specify)
Marital status*

MarriedSingleMarried with kidsSingle with kidsPrefer not to say
Household size*

1234567 or morePrefer not to say
Employment status*

Full-timePart-timeSelf-employedUnemployedStudentRetiredPrefer not to sayOther (please specify)
Education level*

K-12Highschool graduateGEDAttending collegeCollege graduate
Intended use for the computer?*

WorkSchoolPersonalOther
Do you currently own any other computing devices?*

YesNo
What is your main goal in receiving this computer?*
Would you be interested in volunteering or contributing to this program in the future?*

YesNoUnsure
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:
Should be Empty:

Computers for Community - Request a Device