Request a PC (Tucson)

Welcome to Tucson! Please fill out the form below for your computer request and we will contact you shortly:

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? (required)

Family info:

Family Name (required)

Phone Number (required)

Email (if applicable)

Country (required)

State (required)

City (required)

Zip (required)

Home Address (required)

Primary Language spoken at home (required)

Does anyone in the family speak English? (required)
YesNo

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)
YesNo

Does family have prior experience with computers? (required)
YesNo

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.