Individuals application form
From ITShare SA Inc
| Office use only | |
|---|---|
| Application No | Entered into DB on date |
| Date of Application | Entered into DB by |
| Payment received | Invoice no |
An application & handling fee of $40 per computer must be paid before collecting the computer
Contents |
Contact details
Be sure to include at least one contact phone number.
| CONTACT FIRST NAME | CONTACT LAST NAME |
| ADDRESS | |
| SUBURB | |
| STATE | POSTCODE |
| CONTACT NUMBER 1 | CONTACT NUMBER 2 |
Financial information
| CONCESSION CARD NUMBER ............................... | |
| -OR- Select income range that applies. | |
| Under $10,000 per year | Between $10,001 and $20,000 per year |
| Between $20,001 and $30,000 per year | Above $31,001 per year |
| Can you provide proof of financial hardship? (such as Centrelink letter, letter from social worker) | |
| YES | NO |
(NB If you cannot provide proof, we may be able to provide you a low cost solution.)
General information
Why have you applied for for an ITShareSA computer?
Please list who it would benefit, what it would be used for, why you feel you would qualify, and any health or social issues that maybe relevant.
Who referred you to ITShare SA?
.
Existing Computer skills
Please describe the computer skills of the person or people who will be using this computer. Please select one:
| Basic | Intermediate | Advanced |
What Operating System(s) are these person(s) most familiar with (if any)?
Multiple selection(s) allowed:
| Nothing | Windows | MacOS | Linux/Unix | Other (please specify) |
Publicity
As part of our collaboration with Corporate Donors, ITShare & our donors may request interviews for media purposes. If you (or your organisation) would be willing to participate in any publicity events, please indicate.
| YES | NO |
Feedback Are you able to provide feedback about the computer and the benefit it has provided once received from ITShare?
| YES | NO |
Collection and training
Will you be able to arrange collection of your computer at a training session?
| YES | NO |
If not, please provide a reason:
SIGNATURE
NAME
DATE
NOTES (Office use only)
