Nominating Myself

Nomination form must be completed in its entirety and the purpose of need must be no less than 800 characters or 2 paragraphs explaining your need.

Please note: If form is not completely filled in, the nomination may be passed over. Remove text instructions in form fields below and replace with your information.

* We only accept one nomination per household. We do expect all nominators to make a donation of any amount on behalf of the person(s) they are nominating.

My Name:
My Address:
My Address2:
My City:
My State:
My Zip:
My Phone:
My Email:
I am Nominating:	Myself Someone else
Their Name:
How Are You Related:
Their Address:
Their Address2:
Their City:
Their State:
Their Zip:
Their Phone:
Their Email:
Household Income:
Ever Owned A Computer:	Yes No
Why They Should Be Chosen:	Explaination must be no less than 800 characters or 2 paragraphs explaining their need
Other Comments:	Add additional information here. The more we know, the better
Equipment Needed:
Computer Type Preference:
How Many People In Household:	1 2 3 4 5 6 More than 7
Program They Fall Under:
How Many Children:
How Many Teenagers:
How Did You Hear Of Us:
Monetary Gift Amount:
Any Other Comments: