Great Copier Almost Giveaway Application Form

General Information

Applicant Name: *

Enter the name of the person, group or organization that is applying.

Applicant Address: *

Enter address of applicant.

Applicant Description: *

Enter brief description of service or functions of the group or organization.

Applicant Officer: *

Enter the name and phone number of the person who is the officer or head of group or organization that is applying.

Applicant E-mail: *

Enter the email address of the person who is the officer or head of group or organization that is applying.

Applicant 501-3c: *

Are you a 501-3c progran (not necessary to qualify), enter Yes or NO, if YES, also enter program number.

Applicant Contact Persons: *

Enter the name and phone number of the persons we may contact if we have questions.

Copier Infomation

Copier Location: *

Enter the location where the copier will be located, if awarded.

Copier Environment: *

Describe the environment where the machine will be kept.

Copier Estimated Number of Copies used per Month: *

Estimate the number of copies and prints you will use per month.

Will you want to have the copier under a maintenence agreement: *

Yes

We recommend a maintenance agreement which is $0.015 per copy billed on actual copies used. No minimums and no maximum. ( see official rules page for details )

Copier Describe Work: *

Describe the coping, printing, faxing and scanning, if equipped, you will be doing.

Copier Networked: *

Yes

Would you like to have this machine connected to your network.

Current Machine

Do you currently have a multifunction unit?: *

Yes

Current Machine Source:

Current Machine Brand / Make / Model :

If awarded, would this machine be used as your primary machine?: *

Yes

If yes, would you keep your existing machine as a backup or secondary machine?: *

Yes

If no, is there another organization or group whom you may wish to donate it to?: *

Yes

If yes, would you like Western Plains to move it to the new location?: *

Yes

If awarded a machine would you be willing to sign a release that would allow us to use the name of your group or organization in future promotional materials that we may produce.: *

Yes

( Your answer will not be considered in the decision to award machines by the judges )

CAPTCHA

This question is for testing whether you are a human visitor and to prevent automated spam submissions.

Math question: * 2 + 4 =

Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.

By isc at 05/05/2011 - 10:28
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