Computer Request form - Danville Church & Community Tutorial Program

Name of Church/Site

Coordinator

First Name Last Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number

How many computers are at your site?

How many computers are requested?

Check the following security features/methods used to house DCBTP items (equipment, supplies, and/or materials).

Other

Computer Placement Agreement

Upon placement of these computers:

We promise to take full responsibility/liability for each computer listed above.
We promise to provide adequate insurance coverage for each computer listed above.
We promise to pay the insurance deductible should any computer be lost, damaged or stolen.
We promise to return each computer if and when the church’s tutorial program is discontinued.

We understand that the terms of the Computer Placement Agreement are legally binding.

Coordinator's Signature*

Pastor
First Name Last Name