Device Request Form
If you do not have a phone/email, please share contact information for a friend or family member so we can contact you.
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Device Needs
Enter the number of and types of devices you need (1 per person in a qualifying household):
e.g. "1 cell phone, 1 desktop computer, and 1 laptop."
e.g. "1 cell phone, 1 desktop computer, and 1 laptop."
Please describe how you plan to use your device(s):
e.g. "I need a laptop for school. I need to be able to make Zoom calls."
e.g. "I need a laptop for school. I need to be able to make Zoom calls."
Household Members
All members in a qualifying household are eligible to receive a device.
Optional demographic information will be used for anonymized statistics only and will not in any way affect eligibility.
Optional demographic information will be used for anonymized statistics only and will not in any way affect eligibility.
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Select...
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Document
If you have your eligibility document ready, you can upload it here. Otherwise, wait for an email from us and respond to that email with your document.