College Student Desktop Computer Application Form

  1. Name: Date: / /

  2. Address:

  3. City: State: Zip:

  4. Home Phone: ( ) -

  5. Drivers License:

  6. Applying as:

  7. Ethnic Background:

  8. Number in Household: Number of Children:

  9. Marital Status:

  10. Are you head of household?: Yes No

  11. Highest Level of Education Completed:

  12. Employment Status:

  13. Average Gross Total Monthly Household Income: Include ALL household Income, including SSI/SDI/Public Assistance/Child Support including live-in boyfriend/girlfriend/relatives

  14. Do you or anyone in your household own a working computer?:

  15. Does your computer have Internet access?:

    16. Is there anything additional we should know?


    17.

    Please Review Your Application Before Submitting


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