Application for a Computer - Individual or Family

Application for Computer
If you need a computer and receive government financial assistance you are eligible for a low cost subsidized computer. You should be able to pick out and pick up a computer within a few days of completing this application. If you don't hear from us in a few days please call our main telephone number.
Date *  Telephone 
First Name *  Last Name
Street  City 
State  Zip 
Email *  Language 
Demographic Info  Ethnicity 
Household Size  Number of School Aged Children in Household 
Do not include government assistance in household income. Average Household Income 
Assistance List
(pick all that apply)
Tell us how this computer/technical assistance
will make a difference to you or your family.*
If Disabled - General Nature of Disability 
Program Service Request *  
Please note: We are currently running a special holiday computer program for low income families. We have two desktops and two mini-laptops available. These systems have all been upgraded from Windows 7 to Windows 10.

System #1 Dell Desktop Computer: Intel Core 2 Duo CPU; LCD 17” Monitor; keyboard, Mouse Windows 7 or 10 Professional, Microsoft Office Home and Business. 2 GB RAM, 120 GB HDD One Year hardware warranty. $98

System #2 Lenovo IdeaPad laptop S10-3 – 2 GB RAM, 250 GB HDD, Intel® Atom™ 1.66Mhz Processor. Extended battery (long life), Windows 10 home. Limited hardware warranty. $95

#3 Plaidmate Daktech laptop with Windows 10 Pro, Extended Battery. Great for younger folks! Intel® Atom™ 1.66 GHz processor, 250GB Seagate 5400 RPM shock mounted Hard Drive, 2GB memory, 1024 x 600 LCD display, GMA 950 graphics, USB 2.0 Ports: 3, 801.11 b/g/n Wireless, Dimensions 10.5” x 9.3” x 1.5"), Weight 3.4 lb, Windows 10 Pro; Limited hardware warranty. $78

                       You will be required to provide documentation of income.
NOTE: Refurbished Laptop's not recommended for children.
Referral Contact Information
Referral Contact Name  Referral Funded 
Referral Telephone Number  Referral Agency 
Referral Contact Email 
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