Your name*

Your email*

Address Line 1

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City

Postcode*

Phone Number*

Have you been referred by a community group or organisation?
—Please choose an option—YesNo

Evidence of your low-income status will be needed at a later stage, do you have this?*
—Please choose an option—YesNo

What type of tech device are you looking for?*
—Please choose an option—Desktop BundleLaptopSmartphoneTablet

Do you have any additional needs, such as a disability, which might affect the type of technology that is suitable for you?