Computer Recipient Application

Contact Information

First name

Last name

Street address

City

State

Zip code

Telephone Number

Race/Ethnicity

Ethnicity Other

Gender Identity

Gender Identity Other

Do you have DD214 papers showing honorable or general discharge from military service?

How would you rate your computer skills?

Computer Skill Other

What will your computer be used for?

Usage Other

Do you currently have access to a computer? If so, where?

Have you ever owned a computer (i.e. How long ago? What happened to it? Do you still have it? etc.)

Have you taken computer classes before? Please list when and where.

List any specific computer goals you wish to improve on or learn.

Below are the current poverty guidelines. Please select one of the options if they apply.

Which program qualification do you meet?

How did you hear about this program?