Individual Computer Request Application
I. Background Information
1. Name: 2. Phone Number: 3. E-mail Address: 4. Mailing Address: 5. Preferred method of contact: Phone E-mail
II. Eligibility Information Please answer the questions below to assist us in processing your request. You must provide documentation to verify answers to questions 3-5.
1. Number of dependents: 2. Are you a single parent? Yes No 3. Do you qualify for any disability assistance? Yes No If yes, provide a brief explanation:* *Please provide a copy of your Social Security letter indicating your annual award. 4. Are you or any dependents enrolled in any training program or post-secondary educational program? Yes No If yes, provide a brief explanation:* *Please provide a copy of your current or upcoming course schedule or other proof of enrollment signed by an advisor or supervisor. 5. Do you receive any state or federal aid? Yes No If yes, provide a brief explanation:* *Please present documentation to verify that you receive the above mentioned aid. For example, Medicaid card, Food Stamp card, unemployment insurance voucher, etc. 6. What is your annual household income? $0-14,999 $15,000-24,999 $25,000-34,999 >$35,000 7. Please indicate the number of persons in your household of legal age in each employment status category. Full-time: Part-time: Unemployed: Retired:
III. Request Information 1. Please indicate any additional peripherals that you are requesting.* a) Printer Yes No b) Set of speakers Yes No c) Other: *These items are subject to availability. Ink cartridges are not included with printers. 2. Please provide a description of your need for a computer and other requested equipment and how this computer and equipment will be put to use. Please be as thorough as possible.
By submitting this application, I attest that the above information and any documentation provided are true and accurate. I understand that the information, if misrepresented or incomplete, may be grounds for the application's rejection. CTEP also reserves the right to reject applications on the basis of eligibility.
Documentation can be provided by mailing one photocopy of each validation document to this address: DePauw University Community Technology Enhancement Program DePauw University 131 Julian 602 S. College Ave. Greencastle, IN 46135