Request a PC (Phoenix)

We can only provide computers in Arizona and the Philadelphia area at this time. We do not ship computers out of state or out of the country.

This form is for our Phoenix Chapter, click here for our Tucson Chapter, or our Pennsylvania Chapter.

Feel free to download our request form and email to for our Phoenix Chapter. 

Requester Info:

Name of person filling out this form (if applicable)

Requesting Organization (if applicable)

Requester Phone (if applicable)

Requester Email (required)

How did you hear about us? (recommended)

Family info:

Family Name (required)

Phone Number (required)

Email (if applicable)

Home Address (required)

State (required)

City (required)

Zip (required)

Country (required)

Primary Language spoken at home (required)

Does anyone in the family speak English? (required)

How long has this family been in AZ? (required)

Size of Family (required)

Age of Youngest & Oldest Child (required)

Does family currently have internet access? (required)

Does family have prior experience with computers? (required)

What will this family be using their new computer for? (required)

Custom Preferences, Software, Case Manager Contact info, or Comments

By submitting this form, I acknowledge that I understand there is no guarantee a computer will be provided to the Recipient designated above. All computers are provided from currently available inventory and may not be exchanged.

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