Low-cost computer program
This form is to be filled out by a representative for a student or jobseeker.
Applicant's First Name
Applicant's Last Name
Applicant's Email
Applicant's Phone Number
Applicant's Address
***Referral Information***
School counselor, advocate, or case manager
Referral's first name
Referral's last name
Laptop or Desktop?
Laptop
Desktop
Organization
Referral's Email
Referral's Phone Number
Additional information
Who will pick up the computer?
Applicant
Referral
COMPUTERS NOT PICKED UP WITHIN 60 DAYS WILL REQUIRE A NEW APPLICATION BE SUBMITTED
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