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TO APPLY
FOR
A
RECONDITIONED
USED
COMPUTER
PLEASE PRINT THIS FORM, FILL
IT OUT AND MAIL
IT TO:
Street
Tech
Computer
Recycling
Project
2300
El
Portal
Drive,
Suite
F &
G
San
Pablo,
CA
94806
or
FAX
to
510-234-1338
Date:_____________________________________________________________________________
Name
of
organization
_________________________________________________________________________________
Person
completing
application:
______________________________________________________
Job
title
of
person
completing
application:
_____________________________________________
Organization
address:
_____________________________________________________________
Organization
phone(s):
_________________________________________________________________________________
Organization
fax:
__________________________________________________________________
E-mail
address
of
person
completing
application
(if
available):_______________________________________________________________________
Minimum
PC
Specifications:______________________________________________________________________
Computer
specifications
will
vary.
However,
all
computers
will
have
the
following
minimum
specifications:
Software:
WIN98SE
WIN2000
1.
How
many
computers
are
requested?_______________________________________________
(Street
Tech
reserves
the
right
to
limit
the
number
of
computers
to
any
applicant.)
2.
What
is
the
purpose
or
mission
of
the
organization?
__________________________________________________________________________________
__________________________________________________________________________________
4.
Why
are
the
computers
needed?
For
what
specific
purpose
will
they
be
used?
__________________________________________________________________________________
__________________________________________________________________________________
3.
When
was
this
organization
established
or
incorporated?
__________________________________________________________________________________
5.
Who
will
benefit
and
how
many
will
benefit
from
this
donation?
__________________________________________________________________________________
6. When is(are)
the
computer(s)
needed?
__________________________________________________________________________________
7.
If
granted,
who
will
pick
up
the
computer(s)
and
sign
the
release
forms?
__________________________________________________________________________________
8.
Name
and
title
if
different
from
the
person
completing
this
form
__________________________________________________________________________________
9.
How
do
we
contact
this
person?
__________________________________________________________________________________
10.
Any
other
information
you
wish
to
share
that
would
help
the
committee
make
a
decision
about
your
request:
__________________________________________________________________________________
11.
List
three
organizational
references
Name
Address
Phone
a._________________________________________________________________________________
b._________________________________________________________________________________
c._________________________________________________________________________________
12.
Please
attach
documentation
of
non-profit
status
or
state
certifications
of
educational
status.
We
cannot
process
your
application
without
proof
of
non-profit
status.
Acknowledgements
I
certify
that
the
above
statements
are
true
and
complete,
and
that
I am
authorized
to
make
those
statements
and
to
submit
this
application
on
behalf
of
the
applying
organization.
Any
false
statement,
misstatement,
or
omission
of
fact
is
grounds
for
rejecting
this
application
or
for
withdrawing
approval
The
applying
organization
agrees
to
abide
by
the
terms
set
forth
in
the
Criteria
for
Eligibility
for
Reconditioned
l
Used
Computers
and
the
Release
and
Waiver,
and
any
other
documents
provided
by
the
Street
Tech
Computer
Recycling
Project,
and
understands
that
any
donation
is
subject
to
those
criteria
and
the
terms
of
those
documents.
I
acknowledge
that
the
applying
organization
is
willing
to
be
interviewed
for
publicity
purposes
to
promote
this
donation
program,
and
to
allow
photographs
and
text
about
the
donation
for
PR
purposes,
and
that
submitting
this
application
constitutes
a
release
of
those
materials
for
those
purposes.
The
applying
organization
further
acknowledges
that
all
photographs,
text,
and
interview
materials
remain
the
property
of
Street
Tech.
I
acknowledge
on
behalf
(of
the
applying
organization
that
all
decisions
regarding
applications
are
within
the
sole
discretion
of
the
Street
Tech
Computer
Recycling
Program.
Signature
of
organization
officer
Date
___________________________________________________________________________________
Print
name
Mail
completed
application
to:
Street
Tech
Computer
Recycling
Project
2300
El
Portal
Drive,
Suite
F &
G
San
Pablo,
CA
94806
Or,
e-mail
to
barrie@streettech.org
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