First Name (required)
Last Name (required)
Age
Home Address (required)
Parish (required)
Home Phone
Cell Number
Email (required)
What type of ICT device are your requesting? (select one) (required)
Laptop ComputerDesktop ComputerTabletPrinterSmart Phone

List the ways in which the gadget will be utilized in your daily activities (required)



Are you attending any educational institutions currently? If yes, state name of institution. (required)
YesNo
Do you have internet service at home? (required)
YesNo
Are you registered with any of the listed programmes/organizations?
Technology Advancement Programme – T.A.PProgramme for Advancement through Health – P.A.T.HJamaica Council for persons with Disabilities
Are you employed. (required)
YesNo
How did you hear about the Universal Service Fund? (required)