Connect2Compete Computer Distribution and Internet Sign

Connect2Compete Computer Distribution and Internet Sign-up Event Application
 Please complete the entire application to be considered. Incomplete application may be returned.
 One application per family/household.
 Return application to
 If you have any questions, please contact
 Approved applicants will be notified the week prior to the event. Computer must be paid in full in cash
upon pick up at the event. Attendees will also schedule Internet installation appointment with Cox.
 Mr.  Mrs.  Ms.  Dr. Parent’s Name
 Mother  Father
of Student(s) Name:
Home Address:
Apartment Number:
Home Phone: (
Work Phone: (
Cell Phone: (
Do you have child eligible for free school lunch through the National School Lunch Program?  Yes  No
Name of Child’s School
Have you had Cox Internet service in the last 90 days?  Yes  No
Do you currently own a computer in the house?  Yes  No
If yes, does it work?  Yes
Have you ever had Internet service in your home, excluding cell phone service:  Yes  No
Family Income $
Income listed Per  Week
 Month  Year
 African American
 African/Somalia
 Asian
 Chaldean
 Caucasian/White
 Hispanic (Latino/Latina)
 Middle Eastern
 Native American
 No
 Pacific Islander
 Two or more races
 Other (please specify):
Primary Language Spoken:
Do you own a Library Card?
 Yes  No If yes, what branch do you visit most?
Are you in the Military?
 Yes  No  Retired
If yes, what branch do/did you serve?  Army  Marine Corps  Navy  Air Force  Coast Guard
Please indicate number of people living in household by age group (e.g. 1, 2, 3 NOT √ or × marks) :
0-5 years;
6-10 years;
11-17 years;
Adults 18 years of age and over
By submitting this application, I agree that the information presented here is accurate. If required, I understand
that verification of certain facts may be requested. I also authorize Connect2Compete and its partners to
determine my eligibility for discount Internet service, including verifying my existing service(s) with Cox.
South Bay Community Services- STAFF Name CVPN -_______________________________________