REQUEST FOR LAPTOP
Please complete the attached form if you wish to apply and receive a free laptop.
Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
Please enter a valid phone number.
What's your immigration Status?
*
Parolee
Refugee
Asylee
Lawful Permanent Resident
Other
What is your Nationality?
*
If you have your Alien Number, please enter it here:
Will you have transportation to come to the Laptop Workshop if selected?
Yes
No
Are you being referred by an agency? If so, please provide the full name of the case manager and agency name
Full Name
Agency Name
Agency Email
example@example.com
Submit Form
Should be Empty: