Westchester PC-Renew Computer Application
This is an application for a free computer
Today's date *
MM
/
DD
/
YYYY
Recipient's Name: *
Recipient's Phone with area code: XXX-XXX-XXXX *
What type of computer do you want: *
If we do not have a laptop will you accept a desktop *
Recipient Type *
Referring Organization Name: *
Organization Address: Street/ City /State /Zip *
Organization EIN Number (No Dashes) *
Authorized Representative Name, phone numbers and time they can be reached: XXX-XXX-XXXX *
Describe how will you use the computer? *
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