Application for Equipment - Group

Before you continue…

Is your organisation a member of the Digital Support Derbyshire network?
If so, please follow the dedicated application process here.

View our current service status for stock levels and the waiting list.
If the need is urgent, please let us know on the form or contact us.

All information provided will be treated in confidence in accordance with our GDPR Policy.
We may ask for evidence of eligibility.
The final decision on applications lies with the PCrefurb Trustees.

Group Name *

Contact name *

Contact pronouns

Contact address *

Job title/position in the group

Contact Email *

Confirm Email

Contact Phone Number

us you complete

Disclaimer *

I have read and understand the sample disclaimer

The group is *

an educational institution (including a teaching hospital or medical training school)
a Registered Charity (please provide your Charity Registration Number below)
a public museum or library
a funded public research establishment
other (please give details below)

Tick as many as apply.

Please tell us briefly what equipment you would like to request, the reason it is needed and anything else you think is relevant. When you SUBMIT this form you confirm that the information given is true, complete and accurate and that you are authorised to make this application on behalf of the group detailed above. *

Return to Application information page