Agency Referral Form | Community Computers Shop

Community Computers
Low-Cost Technology Referral Form

This form should be used by referring organisations to refer their clients to Community Computers. We provide low-cost technology, discounted for those who are on a low-income. Clients must live within the borough of Stockport or Manchester City Council to be eligible for support.

Referrer name*

Referrer email*

Referring Agency Name*

Referrer Phone Number*

Client name*

Client email*

Phone Number*

Address Line 1

Address Line 2

City

Postcode*

What type of technology does your client need?

Are there funds in place to cover the cost of the equipment?

Yes - Client has means to payYes - The referrer has means to payNo - please contact me to discuss

Would you like us to contact your client via telephone, or would they prefer to reach out to us? Details for contact us will be displayed after form submission.

Please contact me (the referrer) insteadPlease contact my client directly via telephonePlease contact my client directly via e-mailMy client will contact you directly

I wish to refer my client to Community Computers. My client meets the requirements of being on a low-income and they have given me permission to share their contact details with you and have agreed to be contacted if needed.

I agree

Address

Telephone

Email