Agency Name:

Address:

Contact Person:

Contact’s Staff Position:

Contact’s Phone:

Contact’s email address:

Please describe your current IT staff and infrastructure: (e.g. Current Operating System: Windows XP, # of servers, functions of servers, etc.)

Request: Please list any hardware or software you are requesting along with the best prices you have found for each item:

Briefly describe how the addition of this hardware/software will improve the services provided by your agency:

Your request will be reviewed by the Technology Assistance Fund volunteer committee and you will be contacted if additional information is needed or if a site visit to review your present IT infrastructure is requested or deemed advisable.