Program Computer Request
(Only one request per household)
Please fill out this side only, and read this application before signing. Falsification of any information
will prevent you from participating in the New2u Computers program.
Date: _______________________________________
Applicant’s Name: ________________________________________________________________
Parent or Guardian (if applicant is a Minor): _____________________________________________
Address: _______________________________________________________________________
City: ____________________________________________Zip____________________________
Telephone Number_______________________________Alternate #_______________________
You must list EVERY member of your household and include ALL income from all sources
Last Name / First Name
Sex Age
Employer/Source
Monthly Amt.
Total Income for Household
Number of people in the home________
$
Number of people with Disabilities__________
We will be asking for a nominal non-refundable $5 donation in accordance with the income you have
listed to insure this donation does not infringe on your lifestyle or well-being. All donations help fund the
computer program, and have become vital for the program to continue.
**IMPORTANT…PLEASE READ**
There is a waiting list. We will notify you by telephone when your computer is ready. We will attempt to contact you 3
times. If there is no response, we will then issue your computer to the next applicant and your application will be removed. If
your number is out of order, we will discard your application. It is the applicant’s responsibility to inform New2U Computers if
applicants phone number and/or address has changed. It is the applicant’s responsibility to verify that the application and
appropriate proof of disability has been received. Computers will be held for a maximum of 30 days. Applicant must arrange
for transportation of the computer. All systems are assigned on a first come, first available basis.
The computer you receive will be previously owned and does not come with books, manuals, or disks. Set up,
installation and training is your responsibility. Your computer will consist of a PC, monitor, keyboard, and mouse and power
cords. All systems are loaded with Microsoft Windows XP, Open Office and virus protection software. There is a 90 day
warranty on hardware only. New2u Computers is not responsible for any loss of information or data stored on the computer.
For a list of prices and availability of other items please see the Sales Associate at New2U Computers. Applicants must be
Washoe County Residents.
Please sign and date the application assuring that all information provided is true and correct and attach one article of proof
of disability from a Local, State or Federal agency.
Signature_________________________________Date______________________
Disability Resources/ New2U Computers
50 E. Greg St. 102 Sparks NV 89431
775-329-1126 X 216(P) * 775-329-8911 (F) * www.new2ucomputers.com
c:\my documents\new to you\computer request.doc
MAKE
SURE AND
FILL OUT
THE
BACK! *
Office use only
Date of previous Program Computer_______________
Proof of Disability______________________________
Initial Process Date ____________________________
Requested Donation $__________________________
****************************************************************
Date Ready __________________________________
1st Contact Date_______Note____________________
2nd Contact Date_______Note___________________
Final Contact Date_______Note__________________
Pick-up Date _________________________________
Please fill out *
*Which internet connect do you need
o MODEM “Dialup”
OR
o NIC “High Speed”?
Recipients Name____________________________________
Actual Date of Pick-up________________________________
Your signature acknowledges receipt of the above merchandise. It is
recommended that you have someone with computer knowledge help you
with the set-up of this computer. Our technicians are not available for this
task. Any consulting and/or non warranted repairs will be done at the current
rate established by Disability Resources, Inc. Please set up and start using
your computer as soon as possible as your warranty expires in 90 days.
Signature___________________________ Date_______________________
c:\my documents\new to you\computer request.doc