Computer Request Form
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Name *
Name
Address *
Address
City *
City
State *
State
Zip *
Zip
Day Phone *
Day Phone
Evening Phone *
Evening Phone
Date of Application *
Date of Application
Are you currently registered with MCB? *
Are you currently registered with MCB?
Potential Uses *
Please list potential uses for a computer that would be provided by the Memorial Foundation for the Blind:
Please check any items that apply: *
Please check any items that apply:
Required
Other Hardware
Please indicate if any other hardware would be necessary and, if so what type such as printer, scanner, etc.
Purpose of Computer *
Please write a short narrative explaining what purpose this computer would serve the applicant and how it would be used.
MFB CyberSurvey
Do you own a computer? *
Do you own a computer?
What is its operating system?
What is its operating system?
How much internal RAM does it contain?
How much internal RAM does it contain?
How much hard disk storage space dose it have?
How much hard disk storage space dose it have?
What access technology do you use (such as Zoomtex, Jaws, Magic)?
What access technology do you use (such as Zoomtex, Jaws, Magic)?
If you use access technology, how skillful are you at using it?
If you use access technology, how skillful are you at using it?
Clear selection
Basic Computer Skills Assessment
Please answer the questions even if you do not own a computer.

Please rate your computer proficiency using the following scale 1-5 in each of the following skills:

1- Not at all
2- Beginner level
3- Some experience, but in need of practice
4- Reasonable proficient
5- Experienced and very proficient
Use of standard keyboard *
Use of standard keyboard: Rate from 1 to 5 with 1 being not at all proficient and 5 being experienced and very proficient.
Word processing, such as changing fonts, spell-checking, use of text enhancements, formatting, creating tables *
Word processing, such as changing fonts, spell-checking, use of text enhancements, formatting, creating tables. Rate from 1 to 5 with 1 being not at all proficient and 5 being experienced and very proficient.
Creating and accessing emails, including attachments *
Creating and accessing emails, including attachments: Rate from 1 to 5 with 1 being not at all proficient and 5 being experienced and very proficient.
Use of Windows Explorer (my computer) to locate and access computer files *
Use of Windows Explorer (my computer) to locate and access computer files: Rate from 1 to 5 with 1 being not at all proficient and 5 being experienced and very proficient.
Use of scanning and recognition software *
Use of scanning and recognition software: Rate from 1 to 5 with 1 being not at all proficient and 5 being experienced and very proficient.
Working with PDF documents *
Working with PDF documents: Rate from 1 to 5 with 1 being not at all proficient and 5 being experienced and very proficient.
Filling out online forms *
Filling out online forms: Rate from 1 to 5 with 1 being not at all proficient and 5 being experienced and very proficient.
Addressing and printing of envelopes on a LaserJet or Inkjet printer *
Addressing and printing of envelopes on a LaserJet or Inkjet printer: Rate from 1 to 5 with 1 being not at all proficient and 5 being experienced and very proficient.
Keeping personal records on the computer *
Keeping personal records on the computer: Rate from 1 to 5 with 1 being not at all proficient and 5 being experienced and very proficient.
Please print and mail this completed application to:
Memorial Foundation for the Blind
799 West Boylston Street
Worcester, MA 01606

Or email completed application by clicking on Submit button
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