Application for Disability-Related Computer Pricing

Applicant Demographic Information

Name(Required)

First Last

Address(Required)

Street Address City State Zip Code

County(Required)

Contact Phone(Required)

Email(Required)

Enter Email Confirm Email

Family member with disability in household(Required)

Same as above

Different

Name(Required)

First Last

Disability Category(Required)

Please select at least one (1) disability category

If other, please specify(Required)

State or Federal Assistance Benefits Received(Required)

Please select at least one (1) of the following state or federal assistance benefits that you are currently receiving

Verification of State or Federal Assistance Benefits

Please upload, email, fax or mail a copy of the document from the state or federal agency that verifies you are currently receiving the benefit selected. Your application will not be considered complete until the verification document is received.

Max. file size: 256 MB.

If you are unable to upload a file at the time you submit your application, you may send it to us using one of the three methods below:

Scan and email to AskRefurbIT@nau.edu
Fax to 866.463.9390; attention Refurbit program
Mail to:Refurbit Program, AzTAP, 300 W. Clarendon Ave, Suite 475, Phoenix, AZ 85013

After your application has been processed and approved, you will be provided with specific login information and code that will allow you to purchase the computer directly from the RefurbIT/Achieve website with an additional 25% discount above their current discounted prices. Please note that the device you receive will have similar features to the one you ordered, but may not be exactly the same!

If you have questions or need assistance, contact us at AskRefurbIT@nau.edu; 602.776.4670, 800.477.9921

Name

This field is for validation purposes and should be left unchanged.