City of Westminster

COMMUNITY COMPUTERS INDIVIDUAL APPLICATION FORM

 
To apply for a free recycled computer please complete the form below. If you have any questions or need assistance please email Community Computers on communitycomputers@westminster.gov.uk or contact us on Tel: 020 7641 6293 textphone: 07903048763

  Individual Contact Details
  First Name *   
  Last Name *   
  Contact Tel No 1 *   
  Contact Tel No 2  
  Email Address  
  Address *   
  Post Code *   
                   
  Host Organisation Details
  (This is the organisation through whom you are obtaining the computer)  
  Name of Contact *   
  Contact Tel No *   
  Email Address *   
  Name of Organisation *   
  Address of Organisation *   
  Post Code *   
  Website  
  Registered Charity Number  
  You must complete all details marked with an asterisk ( * ).  
 
  Essential Criteria
  You should be able to comply with all the following statements. Please tick to confirm compliance. *   
  I am a resident in Westminster  * 
I am in receipt of a means tested benefit, a state pension or registered disabled  * 
I will allow Westminster City Council Officers access to view any equipment received at all reasonable times  * 
I will undertake to dispose of the equipment in a responsible and environmentally friendly manner  * 
 
 
  How the computer will be used
  Westminster City Council would like you to use a computer to do one or more of the following. Please tick appropriate boxes. (one or more to be ticked)  *   
  I want to increase my access to IT
I want to increase my leisure activities or training opportunities
I want to apply for jobs
 
 
  Computer required
  Please select which you would prefer:  *   
  PC Desktop
Laptop 		 
  This computer will be supplied with a Microsoft Community Licence (Windows XP and Office 2003).
Eligible criteria for the computers include individuals in receipt of low income benefit or disability allowance. 		 
 
  Benefit/Disability Number:
 
  You will be required to complete a Disclaimer Form and provide the following paperwork. (You can view the Disclaimer Form on the Westminster Council website and you will be given a copy to complete on receipt of your computer.)  
  Please supply a photocopy of the following paperwork with the Disclaimer Form on receipt of your computer:
  • Benefit or disability allowance
  • Utility bill
  
 
  Disclaimer
  On receipt of your computer you will be asked to sign a disclaimer stating the following points:  
 
  • I will organise and pay for the collection and installation of the computer
  • If a problem occurs within 7 days of receiving the computer then Westminster City Council will replace the computer with a similar model.
  • If the computer develops a fault I will seek alternative support at my cost
  • If I no longer want the computer, I will dispose of it
    • At my own cost
    • Following government requirements under the Waste Electrical and Electronic Equipment (WEEE) Compliance Scheme
  • I will be responsible for its usage
  • I will not sell or gift on this item
  
 
  Declaration
  I agree to abide by the aforementioned criteria.
To the best of my knowledge the information provided on this application form is correct.
If Westminster City Council agrees to provide me with equipment, this will be used exclusively for the purpose(s) described.