The Contra Costa County Employment and Human Services Department (EHSD) has implemented a computer equipment donation program for recipients of CalFresh, CalWORKs, General Assistance, and Medi-Cal in an effort to help bridge the digital divide for residents of Contra Costa County. The Technology Works Personal Computer (PC) Equipment Donation Program provides a total solution for customers of EHSD, including the PC, internet access, training, and maintenance service at “low to no” cost. Register for a chance to receive a newly refurbished computer by completing all of the following information. You can also download a print version of this form here.Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Email* Phone*CalFresh/CalWORKs/General Assistance/ Medi-Cal Case Number:*By completing this entry form and clicking the “submit” button below, you affirm that you meet the following conditions and are giving your permission for the Contra Costa County EHSD to share the information collected on this entry form with its selected computer vendor. This information will be used to randomly select a recipient to receive a newly refurbished computer.* Yes, I affirm that I am currently receiving CalFresh, CalWORKs, General Assistance, and/or Medi-Cal benefits from the Contra Costa County Employment & Human Services Department. Yes, I affirm that my CalFresh, CalWORKs, General Assistance, and/or Medi-Cal case is currently in good standing with program requirements. Yes, I affirm that I will not sell the PC or PC equipment if selected to receive a newly refurbished computer. Yes, I understand that the Contra Costa County Employment & Human Services Department will share my information with its selected computer vendor if my case is selected to receive a newly refurbished computer. All information will be treated as confidential. CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.