Organizational Computer Request Application
I. Background Information
1. Organization: 2. Contact's Name: 3. Phone Number: 4. E-mail Address: 5. Mailing Address: 6 . Preferred method of contact: Phone E-mail 7. EIN Number or County-District-School Code Number:
II. Eligibility Information Please answer the questions below to assist us in processing your request.
1. Does your organization have a non-profit tax exempt status as defined in Section 501(c)(3) of the Internal Revenue Code?* Yes No *Non-profit organizations must provide a copy of their 501(c)(3) letter. 2. Is your organization a public or private nonprofit K-12 school or community college?* Yes No *Please provide proof of your institution's accreditation. 3. Is your organization a religious organization? Yes No If yes, does your organization have a 501(c)(3) tax exempt status and a secular community mission? *Please provide a copy of your 501(c)(3) letter.
III. Request Information 1. How many computers are you requesting? 2. Please indicate the quantity of any additional peripherals that you are requesting.* a) Printer b) Set of speakers c) Other: *These items are subject to availability. Ink cartridges are not included with printers. 3. Please provide a brief description of your need for a computer and other requested equipment and how this computer and equipment will be put to use.
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