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.