Low-Cost Computer Application
Please complete the form below to purchase your low-cost computer. Once submitted you will be directed to SDFF's online store to optionally pay online and instructions to pay in person.
Contact Information
Date
-
Month
-
Day
Year
Date
Full Name
*
First Name
Last Name
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
*
example@example.com
Phone Number
*
Customer Survey
Age Range
*
Please Select
18 - 25
26 - 45
46 - 54
55 - 62
62 and over
Decline to State
Gender
*
Please Select
Female
Male
Prefer to self-describe
Decline to State
Self-describe gender
Ethnicity
*
Please Select
Asian
Black / African American
Hispanic / Latino
Native American
Native Hawaiian / Pacific Islander
White
Multi-racial
Decline to state
Are you currently employed?
*
Please Select
Yes
No
Decline to State
Education (highest level completed)
*
Please Select
No School
Some High School (No Diploma or GED)
High School (Diploma or GED)
Some College (No Degree)
Associate Degree
Bachelor’s Degree
Master’s Degree
Technical/Trade/Vocational School
Decline to State
Annual Income
*
Type in 'decline to state' if you wish to skip.
Number of dependents: people you are financially responsible for (including yourself)?
*
Please Select
1
2
3
4
5
6
7
Total number of people living in your household (including yourself)
*
Please Select
1
2
3
4
5
6
7
Decline to State
What computer are you interested in?
*
Please Select
Desktop
Laptop
How do you plan to use your computer to enhance your personal or professional development with your computer?
*
Please Select
Education and online learning
Job searching and career advancement
Running a small business or entrepreneurship
Improving digital literacy skills
Connecting with family and friends
Accessing county resources and other essential services
Other (Please specify): ___________
Please specify how you would use your computer?
How did you hear about us?
Please Select
Internet Search
Event
Social Media
SDFF Staff Member
Other Nonprofit
Other________
Please specify
Terms and Conditions
I attest that I receive the required benefits or are a member of one of the listed qualified groups
*
Please Select
I receive EBT (Food stamps, Cal Fresh, etc.)
I receive Medical, Medicare, etc.
I am retired
I am a non-profit Employee
I receive SSI or SSA
I am a Veteran/Active Duty Military
I can provide proof of income (W2 and pay stubs)
I am a foster parent
I have a certified disability
I am a student
None of the above
Please select all that apply
If approved to receive a computer, do you agree to use your computer for personal use and not sell it?
*
Please Select
Yes
No
I acknowledge that the computers provided by SDFF are refurbished and may exhibit minor cosmetic imperfections.
*
Please Select
Yes
No
I agree to and understand these terms.
*
Please Select
Yes
No
Comment Section
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Age Range
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