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LOAVES FISHES _ COMPUTERS INC

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					 LOAVES, FISHES & COMPUTERS, INC.
                                       Computer System Application

Date of Application                                Referred By (If applicable)
Name of Applicant                                                     Primary Phone #
Address
Email
Family Size                   Age of Applicant                     Total Monthly Gross Income $

              (if your application is approved you will need to show proof of income before your computer can be issued.)

Source of Income (Work, Government, Both)

Is the recipient a student?                    (If “yes”) If so, what grade is he or she in?

Is the recipient housebound?                                                                                                   _

What will be the primary use of the computer?



Is there a reason the recipient can not work?                                                                                      _

Ages of those using the computer

Will there be Internet access available?                              Wired?      Wireless?      (circle one or both)

Is there a functional computer in the household currently?                         (If “yes”) How Many?                            _

Does the recipient have any previous computer experience?

If yes, do you have experience with                 PC       MAC               Ubuntu/Linux                 (Circle one or both)

Do you have a functioning printer?                                            _

Do you currently have functioning computer equipment that can supplement our donation?                                                 _
                        (For example if you already have a monitor or printer this may expedite our donation.)


                       Please use the backside of this paper if there are any special
                         circumstances or needs you would like to share with us.

                    Every effort will be made to place a computer with all qualified applicants.
      Our screening committee will review all applications and you will receive an answer within two weeks.
                             In most cases priority will be given to school age children.
     Please note that the need for computers often surpasses our inventory so you may be placed on a waitlist.
                                            Return this application to:
                                        348 Roberts Ave. Seaside, CA 93955

				
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