First Name * Last Name * Organization *

Physical Address 1 *

Physical Address 2

Position in Organization *

City *

State *

Phone Number *

E-Mail Address *

Are you a 501(c)3?

If you are not a 501(c)3,
what kind are you?
Yes No


Please tell us more about your organization's needs: (check all that apply)
Money Computers & Parts Software
Services
(cleaning, gardening, etc)

What Kind?
Technology Consumables
(printer paper, ink, toner, etc)

What Kind?
Other Needs Not Listed
(fund raising, etc)

Please List:

Questions or Comments: