Digital Support Derbyshire Network - Application for Equipment for an Individual

connectivity membership Select

Application for Equipment

Digital Support Derbyshire Network membership *

I confirm that the organisation I represent is a member of the Digital Support Derbyshire Network.

Referrer Details

Referrer Name *

First

Last

Title (Mr, Mrs, Ms, Dr, etc.)

Referrer pronouns

Referral Organisation *

Referrer Address *

Address Line 1

City

State / Province / Region

Postal Code

Referrer Job Title/Connection with Client *

Referrer Email *

Confirm Email

Referrer Phone Number

Client Details

Client Name *

First

Last

The person that will use the equipment

Title (Mr, Mrs, Ms, Dr, etc.)

Client pronouns

Preferred Name

Client Address *

Address Line 1

City

State / Province / Region

Postal Code

Client Date of Birth *

Ethnicity *

Gender *

The Client is a school or college student *

The first port of call for devices should be the student's school/college as the body responsible for meeting their educational needs, including provision of alternative work if devices are not available. If, as Referrer, you feel there are exceptional extenuating circumstances please provide details below.

Client Email

Confirm Email

Client Phone Number

Agreement *

The Client has read the Equipment Disclaimer (see above).

Equipment Details

Main reason(s) for request *

Improved employment prospects / job searching
Training / education
Finance / household management
Social interaction and support activities
Management of health needs
Other (please explain in the box below)

In order to support this application, please briefly explain how the Client will benefit from receiving equipment. *

Does the Client have access to a broadband or Wi-Fi connection to access the Internet? *

Yes
No
Other (please explain below)

Other Wi-Fi connectivity *

Data connectivity: We have available a limited number of Wi-Fi hotspots and data SIMs. Please indicate below if these may be needed.

Which Operating System? Please consider asking for ChromeOS Flex rather than only Windows. This is a lightweight, fully-featured Google-based operating system. Read more about it here...

Equipment preferences (subject to availability). Select all that would be acceptable. *

Desktop computer (Wi-Fi capable) - Windows (Microsoft)
Laptop - Windows (Microsoft)
Laptop - ChromeOS Flex (Google)
Tablet - Android (Google)
Wi-Fi hotspot and data SIM - Vodafone 40GB per month for 6 months
SIM(s) only - dependent on availability, EITHER Vodafone free calls, texts, 40GB data per month for 6 months, top-up automatic OR VMO2 free calls, texts, 25GB data per month, top-up by text required (please state below how many SIMs are required)

Please contact us if you need more information about these options. We can provide compact desktop systems.

Limited access to technology *

I, the Referrer, confirm that the Client does NOT already have access to usable equipment, either their own or borrowed, including at a public facility, to meet their needs.

The Client that will use the equipment... *

has a low income and is in receipt of benefits or other financial support
has a disability
other (please explain below)

Tick as many as apply. We reserve the right to ask for evidence to support these choices.

Collection or delivery

If we are able to provide equipment for this referral, we will contact you, the Referrer, to discuss collection or delivery. Please note we cannot normally ship desktops outside High Peak.

PCrefurb has permission to contact the client directly if necessary *

Any other relevant information

Information cannot be changed beyond this point. Click Next to proceed to the Declaration and to SUBMIT this Referral.

Referrer Feedback Agreement and Declaration *

The Referrer agrees to give feedback to PCrefurb not later than six months after equipment has been provided to confirm it has been used for its intended purpose. When you SUBMIT this form you, the Referrer, confirm that the information given is true, complete and accurate. If applying on behalf of an individual, you confirm that you are authorised to do so.

GDPR Agreement *

I consent to this website and PCrefurb storing the submitted information so PCrefurb can respond to this Referral. The referred client agrees to PCrefurb processing the submitted information in order to respond to the referral.