Tech Spark Initiative Inc. Program Eligibility Application Form

Tech Spark Initiative Inc. Program Eligibility Application Form

Please complete this application to determine your eligibility for our PC assistance program. All information will be kept confidential and used solely for qualification purposes.
Are you a Resident of Northwest Florida*

YesNo
Applicant's Full Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Residential Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Household Size*
Household Income (IRS Adjust Gross Income)
(Adjusted gross income can be found on IRS Form 1040 Line 11 or 1040EZ Line 4)
Are you enrolled in any of the following government assistance programs?*
Please specify your primary intended use for the PC*

Education / SchoolworkEmployment/Job SearchTelehealth / MedicalCommunication / Social ConnectionPersonal UseOther
Do you have reliable internet access at your residence?*

YesNo
Describe how you plan to use the PC and how it will benefit you or your family.
Upload proof of enrollment in government assistance programs or proof of income (e.g., tax return with sensitive info redacted).

Cancelof
Upload additional documentation if needed (optional).

Cancelof
Signature

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Demographic Information
Your answers in this section are optional. We use this summary data only to fulfill reporting obligations and strengthen our funding applications (grants and donors). Individual responses are kept confidential and will never be tied to your personal identity.
Gender (Optional)
Race (Optional)
Ethnicity (Optional)
Age Range (Optional)
Should be Empty:

Tech Spark Initiative Inc. Program Eligibility Application Form

Demographic Information