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.
Format: (000) 000-0000.
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
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Laptop
Desktop PC
Monitor
Unsure - I need advice
Other (please specify)
Do you have reliable access to internet/Wi-Fi at home?
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Yes
No
Please select your preferred language(s):
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English
Spanish
Russian
Ukraine
Chinese
Vietnamese
Other (please specify)
Which race or ethnicity best describes you?
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American Indian / Alaskan Native
Asian / Pacific Islander
Black / African American
Hispanic / Latino
White / Caucasian
Prefer not to say
Multiple ethnicity / Other (please specify)
Age
*
Under 18
18-24
25-34
35-44
45-54
55-64
65-74
75 and older
Prefer not to say
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
Prefer not to say
Household size
*
1
2
3
4
5
6
7 or more
Prefer not to say
Employment status
*
Full-time
Part-time
Self-employed
Unemployed
Student
Retired
Prefer not to say
Other (please specify)
Education level
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K-12
Highschool graduate
GED
Attending college
College graduate
Intended use for the computer?
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Work
School
Personal
Other
Do you currently own any other computing devices?
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Yes
No
What is your main goal in receiving this computer?
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Would you be interested in volunteering or contributing to this program in the future?
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Yes
No
Unsure
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
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