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2. If you are a Fairview resident and would like to receive assistance from the City of Fairview Digital Assistance Pilot Program please submit the form below for consideration. If you are unable to complete this application online, please contact the program administrator by emailing midgleyn@ci.fairview.or.us or calling (503) 674-6236 for application assistance. This pilot program is funded and supported by the City of Fairview and ARPA funds.

   *Completing this application is not a guarantee of assistance. Assistance is based on available program resources.

4. Applicant Name*
6. Physical Address*
8. Phone Number*
10. Email Address
12. Preferred Contact Method*

    1. Phone
    2. Email
    3. Text
13. Do you need a translator/interpreter?

    1. Not Applicable
    2. Spanish
    3. Other
15. Please specify
17. Does someone in your household currently own a computer or tablet device that can connect to the internet?

    1. Yes
    2. No
19. Are you interested in receiving a computer from the City of Fairview?
21. Do you currently have internet service at your home?

    1. Yes
    2. No
23. Are you interested in receiving financial assistance to help pay for internet service?

    1. Yes
    2. No
25. Are you currently enrolled in the Affordable Connectivity Program?*

    1. Yes
    2. No
27. Please upload proof of enrollment in the program.
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

* indicates a required field