Cops and Computers for the Community, Inc 

         “Changing lives, one computer at a time” 
                 6937 Crown Lake Dr, Gibsonton Fl 33534 
                cops_and_computers@juno.com 
 
 
 
 
 
Please provide this information so we can prepare just the right computer for your needs. 
 
Name of Adult (or student if in college): 
 
Age of user(s): 
 
Date of request: 
 
Email address: 
 
Home address: 
 
City, State, ZIP 
 
Phone Number: 
 
Computer uses and requirements.  Tell how the computer will be used and the ages(s) of the users.  For example: children need learning software; high school and college students need programs to complete school assignments.  Computers used primarily for e-mail, will need word processing software. 
 
My needs: 
 
 
 
 
 
 
 
 
 
 
 
 
Official use:  Computer issued _______________________________________ 
 
                       Monitor issued    _______________________________________