Assistive Technology of Ohio
Computer Refurbish and ReDistribution Program
Toll Free (866) 801-7306 Phone (614) 293-9132 Fax (614) 293-9127 Web site: www.atohio.org Building L 445 E. Dublin-Granville Road Worthington, OH 43085 Email: atohio02@osu.edu
Application for a Computer
(Promoting independence for People with Disabilities in Ohio through computer recycling) Please complete this form and return it to the above address, attaching participation agreement, the Microsoft recipient agreement, and a letter from a Service Provider, on an Official Letterhead e.g. Doctor, Pediatrician, Physiotherapist, Psychologist, Case Management Officer, etc., stating that the applicant does have a disability. Applicant must be a legal resident of the state of Ohio. Only one application per household.
PLEASE PRINT Name (Child or Adult to Receive Computer): Address of Recipient (cannot be shipped to a P.O. Box): (Phone) Home: Sex: Race: Work: City: Cellular: Disability (optional): Relationship: Age: Zip:
Contact Person (if applying on behalf of child or adult): Referral Organization (if applicable): Phone: Fax:
Email:
Describe your need for a computer? What do you plan on using the computer for?
Please indicate your level of experience in using a computer (Please circle): 1 No Experience 2 3 Somewhat Experienced 4 5 Very Experienced
Where do you plan to get the computer training you need? (if necessary)
Have you tried to obtain a computer from another source? If yes, what have you tried? What were the results of your efforts?
Other comments you think will help AT Ohio understand your need for a computer.
How did you hear about our program?
Additional Comments:
Note: It is the participants responsibility to update AT Ohio with address and/or phone number changes. If participant moves out of the state of Ohio, they will no longer be eligible for the program. AT Ohio will contact participant when a computer becomes available. Length of time on waiting list depends on the number of computer donations received. Upon notification, participant will be required to send a check or money order in the amount of $50 made out to: Mike’s Computer Solutions.
AT Ohio Use Only
____ Application ____ Participation Agreement ____ Disability Verification Letter ____ Signed Microsoft Agreement Date: ________ Date: ________ Date: ________ Date: ________ ____ Shipping Payment ($50) ____ Computer Documentation ____ UPS Email Notification ____ Follow-up Survey Date: ________ Date: ________ Date: ________ Date: ________