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Adult Desktop Computer Application Form
Name:
Date:
/
/
Address:
City:
State:
Zip:
Home Phone: (
)
-
Drivers License:
Applying as:
--- Select ---
Low Income
Disability
Both
Ethnic Background:
--- Select ---
Caucasian (White)
Afican-American (Black)
Hispanic
Bi-racial
Asian
American Indian
Pacific Islander
Number in Household:
Number of Children:
Marital Status:
--- Select ---
Single
Married
Divorced
Separated
Widow/Widower
Are you head of household?:
Yes
No
Highest Level of Education Completed:
--- Select ---
8th Grade or Less
Some High School
High School Degree
Some College (No Degree)
Associates Degree (Community College)
Bachelors Degree (4-Year Degree)
Masters Degree (Advanced Degree)
Employment Status:
--- Select ---
Unemployed
Laid Off
On Disability
Workman's Comp
Full Time
Part Time
Retired
Average Gross Total Monthly Household Income:
Include ALL household Income, including SSI/SDI/Public Assistance/Child Support including live-in boyfriend/girlfriend/relatives
Do you or anyone in your household own a working computer?:
--- Select ---
Yes
Yes, but it's not working
Yes, but too old
No
Does your computer have Internet access?:
--- Select ---
Yes, Dial-up
Yes, DSL
Yes, Cable
No
Is there anything additional we should know?
Please Review Your Application Before Submitting
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