Community Computer Connection

Request Receipt of Equipment

	Effective January, 2008 there will be a small administrative fee applied to all equipment requests.


* Contact Name:
* Contact Email:
* Contact Phone Number(s)

Organization:
Director of Organization and Title:
Director's Email Address:
Address:
City :
State:
Zip Code:
Country:
Phone:
Fax:
Website:
* FEIN (Federal Employer Identification Number) ex: [XX-XXXXXXX]:
Org. Type:	Nonprofit School

Describe the mission of your organization (50 words or less):
How did you first hear about Community Computer Connection?:
Please describe the clients or students whom you serve, including numbers served, need and demographics (50 words or less):
Note:	We can provide fully refurbished PC desktop systems including a Pentium 4 computer, keyboard, mouse, mouse pad, power cords, and a monitor.
Number of Desktop Systems for use in a computer lab or classroom:
Number of Desktop Systems for Staff Support Use:
Number of Desktop Systems that will be awarded to your clients for use at home:
Number of Laptop Systems Requested:
	Please list other computer equipment that would assist your organization. These items will only be provided if we have them in our inventory at the time of your request. Possible equipment would include printers, and networking equipment:


Briefly describe how your organization will use the requested computers (50 words or less):
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	You must fill in the fields marked with a *