Name _____________________________________________ SS#__________________
Address ________________________________________________
City _____________________________State____________Zip Code___________
Phone Numbers: Home:_______________ Work: ______________ Cell:______________
Age ___ Occupation ______________________ Annual Family Income $____________
Do you currently own any computer? Yes __No___ How many? _______________
Do you know have internet access? Cable ___DSL ___ Dial Up _____
What will you use this computer for?
Word Processing ____Record Keeping ____Internet ____Games____ School____
Other (describe)________________________________________________________
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Please tell us why you want us to donate a computer to you.
(Use the back of this form if you need more room.)
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Signed _________________________________________ Date _________
Please mail completed application to: PCRenew
at the address above.
Note that we cannot ship or deliver computers. If approved it will be
your responsibility to arrange for a pick up.
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