Name
*
First Name
Last Name
Birthday
*
MM
DD
YYYY
Phone
(###)
###
####
Which city are you/your client primarily located in?
*
Message
Is this your first time requesting a device from the Digital Inclusion Project?
*
We do not give out multiple devices or replace lost or stolen devices.
Please select the option that best describes your current living facility.
*
Staying with friends/relatives
Sleeping outside
At an emergency shelter
Correctional facility
Treatment facility/detox
Hospital
Private market - single room occupancy hotel
Private market - own unit/suite
Other (please specify)
Please provide more information on your current housing situation.
Address
If you are requesting a desktop or laptop computer, please provide with us a fixed address to ensure the device remains safe in your possession.
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Do you have access to a reliable source of Internet/WiFi?
*
If you're requesting a desktop computer, what is your Internet/WiFi setup at home?
*
Are you able to purchase a charger for your device? Please note that we may not always have chargers available.
*
If you are requesting a cell phone, are you comfortable receiving a flip phone?
*
Please note we may sometimes only have flip phones available.
Are you able to finance a mobile phone? (i.e. buy a pre-paid SIM card, pay a monthly plan, etc.)
*
Thank you for submitting your application! If your request application is approved, keep an eye for an email from us in your inbox. Once contacted, we will hold your device for up to one week. If you have not received a reply for over a month, reach out to us for an update on the status of donations.
